Alternative Dispute Resolution Systems Regarding Private

Transkript

TURKEY
Alternative Dispute Resolution Systems
Regarding Private Insurance
SİGORTA HUKUKU TÜRK DERNEĞİ
TURKISH CHAPTER OF AIDA
İstanbul, 4 M
ay 2012
(AIDA TURKEY)
Alternative Dispute Resolution Systems Regarding Private Insurance
April 2014
3XEOLVKHU6LJRUWD+XNXNX7UN'HUQH÷L%\NGHUH&DGGHVL%\NGHUH3OD]D1R.DW
/HYHQWøVWDQEXO7HO
Front Page Design: Ümran Arslan
3ULQWLQJ+RXVHg]GLO%DVÕPHYL*DOLS'HGH&DG%H\R÷OXøVWDQEXO7HO
TURKISH CHAPTER OF AIDA
Foreword
'XHWRYDULRXVUHDVRQVXQDYRLGDEO\GLVSXWHVDULVHEHWZHHQLQVXUHUVDQG
SROLF\KROGHUV,QVSLWHRIWKHIDFWWKDWDSRSXODUPHDQVDQGLQDQ\FDVHWKH
XOWLPDWHZHDSRQWRUHVROYHVXFKGLVSXWHVLVYLDWKHUHVRUWWRVWDWHFRXUW
OLWLJDWLRQ QHYHUWKHOHVV DQRWKHU PHDQV RI UHVROXWLRQ RI VXFK GLVSXWHV LV
WKHVRFDOOHG$'5$OWHUQDWLYH'LVSXWH5HVROXWLRQVFKHPHVDQGPHWKRGV
ZKLFKDUHIUHTXHQWDQGRIWHQOHDGWRVXFFHVVIXOUHVXOWV
7KLVERRNOHWFRQWDLQVDUWLFOHVZULWWHQE\H[SHUWVRIGLIIHUHQWMXULVGLFWLRQV
7KH DLP LV WR JLYH WKH UHDGHU D FRPSDUDWLYH LGHD DERXW H[LVWLQJ $'5
PHWKRGVLQWKH¿HOGRISULYDWHLQVXUDQFH
,ZRXOGOLNHWRH[SUHVVP\ZDUPWKDQNVWRWKHDXWKRUVDOOOLQNHGWR$,'$
IRUWKHLUPRVWYDOXDEOHFRQWULEXWLRQV
Samim Ünan
Chairman
AIDA Consumer Protection and Dispute Resolution
Working Party
Content
The German Insurance Ombudsman System
3URI'U-HQV*DOMaître en droit
for Insurance Disputes - An Australian Perspective
&KULVWRSKHU5RGGB.Juris, LLB, Grad Dip Ins Law, ANZIIF (Fellow)
Resolving Consumer Insurance Complaints
in the UK - The Financial Ombudsman Service
0LFKDHO0HQGHORZLW]Consultant, Norton Rose Fulbright LLP, London 66
La Mediation En Assurances En France
$QQH3pOLVVLHUProfesseur à l’Université Montpellier I (France)
Médiateur du groupe MMA
Alternative Dispute Resolution Sweden
5RVH0DULH/XQGVWU|PRose-Marie Lundström Advokat AB
The Function and Operation
of the Insurance Ombudsman
in Greece through the Independent Authority
of the Consumer Ombudsman
'U.\ULDNL1RXVVLD
The Finnish System for Dispute Resolutions
7DLVWR+XMDODLegal Counsel
If P&C Insrurance Company Ltd, Finland
Member of the AIDA Presidential Council and the Executive Committee
Dispute Resolution in Insurance:
The South African Ombud
3URI%LUJLW.XVFKNHUniversity of Pretoria 100
Turkish Special Arbitration Scheme for Claims Against Insurers
'U6DPLPhQDQAIDA Turkey 111
The German Insurance
Ombudsman System
Prof. Dr. Jens Gal, Maître en droit
Jens Gal is entrusted with a Chair for European Insurance Law with a main focus on
LQVXUDQFHVXSHUYLVRU\ODZDWWKH8QLYHUVLW\RI)UDQNIXUW*HUPDQ\3URI*DOÀQLVKHGKLV
legal studies in Frankfurt and Lyon, France and passed the First and Second States Exam
in the state of Hesse. He has been a regular lecturer at the Institute for Law and Finance in
)UDQNIXUWVLQFHDQGDWWKH8QLYHUVLW\/XPLqUH,,LQ/\RQVLQFH*DO·VVFLHQWLÀF
focus is largely on issues of insurance contract law and insurance supervisory law but also
on the law of civil procedure with a main interest on arbitration matters. Gal is, inter alia,
a member of the interdisciplinary International Center for Insurance Regulation (ICIR)
DQGRIWKHVFLHQWLÀFDGYLVRU\ERDUGRIWKH$VVRFLDWLRQIRUWKH$GYDQFHPHQWRI7HDFKLQJ
of Insurance Matters of the University of Frankfurt and he is the current secretary of the
*HUPDQFKDSWHURIWKH$VVRFLDWLRQ,QWHUQDWLRQDOHGH'URLWGHV$VVXUDQFHV$,'$
I. Introduction
)RUPDQ\\HDUVWKHSUROLIHUDWLRQRIQHZRPEXGVPDQV\VWHPVLQ*HUPDQ\
KDVEHHQPHWZLWKDOPRVWXQLYHUVDODFFODLPE\SROLWLFDODQGHFRQRPLFDFWRUV
DQGWKHSXEOLFDWODUJH7KHGHYHORSPHQWRIWKHRPEXGVPDQLGHDWRRNSODFH
LQWZRYHU\GLVWLQFWVSKHUHV2QWKHRQHKDQGRPEXGVPHQZHUHLQVWLWXWHG
LQWKHSROLWLFDOSXEOLFODZVHFWRU1+HUHWKHRPEXGVPDQLVXVXDOO\DVWDWH
RI¿FLDODSSRLQWHGDQGHQWUXVWHGZLWKWKHWDVNRIVHUYLQJDVDQDGYRFDWHIRU
WKHFLWL]HQV¶LQWHUHVWVYLVjYLVSROLWLFDORUDGPLQLVWUDWLYHDFWLYLWLHV2QWKH
RWKHUKDQGRPEXGVPDQV\VWHPVKDYHDOVRÀRXULVKHGLQWKHSULYDWHHFRQRPLF
VHFWRU2+HUHRPEXGVPHQDUHLQWHQGHGWRUHPHGLDWHDGLVHTXLOLEULXPWKDW
H[LVWV EHWZHHQ DQ HFRQRPLF DFWRU DQG LWV FRQWUDFWXDO SDUWQHU ± ZKLFK LV
XVXDOO\DFRQVXPHU±E\SURYLGLQJWKHODWWHUZLWKDQHI¿FLHQW\HWLQH[SHQVLYH
GLVSXWHUHVROXWLRQPHFKDQLVPIRUFRPSODLQWVDJDLQVWWKHIRUPHU
1
)RU DQ RYHUYLHZ RQ VRPH SXEOLF VHFWRU RPEXGVPHQ FS i.a. HAAS 'HU 2PEXGVPDQQ
DOV ,QVWLWXWLRQ GHV (XURSlLVFKHQ 9HUZDOWXQJVUHFKWV ± =XU 1HXEHVWLPPXQJ GHU 5ROOH
GHV 2PEXGVPDQQV DOV 2UJDQ GHU 9HUZDOWXQJVNRQWUROOH DXI GHU *UXQGODJH HXURSlLVFKHU
2PEXGVPDQQ(LQULFKWXQJHQ7ELQJHQ
2
$Q RYHUYLHZ RQ RPEXGVPHQ LQ WKH ¿QDQFLDO VHFWRU PD\ EH IRXQG LQ BRÖMMELMEYER
'HU 2PEXGVPDQQ LP )LQDQ]VHNWRU LQ :0 =HLWVFKULIW IU :LUWVFKDIWV XQG
%DQNHQUHFKWSS±DWIRUIXUWKHUVHFWRUVSURYLGLQJDQRPEXGVPDQ
V\VWHPFSHJKWWSZZZJDOOLLQVWLWXWGHYUBRPKWP
10
7KH*HUPDQ,QVXUDQFH2PEXGVPDQ6\VWHP
2QH RI WKH PRVW VXFFHVVIXO RPEXGVPDQ SURFHGXUHV LQ *HUPDQ\
LV WKH RQH SURYLGHG E\ WKH *HUPDQ LQVXUDQFH XQGHUWDNLQJV WKH
Versicherungsombudsmann ZKLFK VLQFH LWV LQFHSWLRQ LQ KDV
DWWUDFWHGDQDQQXDODYHUDJHRIDERXWFRPSODLQWVUHDFKLQJDQHZ
SHDNLQZKHQDOPRVWFRPSODLQWVZHUHORGJHG4$W¿UVWVLJKW
RQH PLJKW EH P\VWL¿HG DV WR KRZ WKLV LQVWLWXWLRQ PDQDJHG WR JDUQHU
HTXDO VXSSRUW IURP LQVXUHUV DQG SROLF\KROGHUV DOLNH 2QH RI WKH UHDVRQV
FDQFHUWDLQO\EHVHHQLQWKHIDFWWKDWXQOLNHPDQ\RWKHURPEXGVPHQWKH
Versicherungsombudsmann LVQRWOLPLWHGWRPDNLQJUHFRPPHQGDWLRQVWR
WKHSDUWLHVLQWKHVHQVHRIDUHFRQFLOLDWLRQSURFHGXUHEXWLQGLVSXWHVXS
WRDQDPRXQWRI¼LVHPSRZHUHGWRWDNHGHFLVLRQVELQGLQJRQWKH
LQVXUHUEXWQRWWKHFRPSODLQDQW7KLVLVKRZHYHUEXWRQHIDFHWRIWKH
DWWUDFWLYHQHVVRIWKH*HUPDQLQVXUDQFHRPEXGVPDQDQGWRXQGHUVWDQGLWV
VXFFHVVRQHQHHGVWRWDNHDPRUHGHWDLOHGORRNDWLWVVWUXFWXUH
II. Historical Development
:KLOVWWKHFUHDWLRQRIDQLQVXUDQFHRPEXGVPDQKDGEHHQXQGHURFFDVLRQDO
GLVFXVVLRQVLQFHWKHVWKHIRXQGDWLRQRIWKHVersicherungsombudsmann
e.V. E\ WKH *HUPDQ LQVXUDQFH LQGXVWU\ LQ ZDV UDWKHU EHODWHG6 in
FRPSDULVRQ WR WKH LQVXUDQFH VHFWRU RI PDQ\ QHLJKERXULQJ FRXQWULHV
2QO\GXULQJWKH¿UVWWKUHH\HDUVGLGWKHFRPSODLQWVDYHUDJHDPRXQWWRD³PHUH´
6LQFHWKHQWKHDYHUDJHKDVFRQVWDQWO\UHPDLQHGEHWZHHQDQGFRPSODLQWV
per annumIRUWKHQXPEHUVLQWKH¿UVWIHZ\HDUVFSHJOMBUDSMANN FÜR VERSICHERUNGEN
-DKUHVEHULFKWS
4
7RFRPSDUHWKH*HUPDQ3ULYDWH%DQNLQJ2PEXGVPDQ±ZKLFKKRZHYHULVRQO\FRPSHWHQW
IRUGLVSXWHVZLWKSULYDWHEDQNV±KDVHYHQLQKLVPRVWVXFFHVVIXO\HDUVQHYHUDWWUDFWHG
HYHQKDOIWKHDPRXQWRIFRPSODLQWVFSOMBUDSMANN DER PRIVATEN BANKEN7lWLJNHLWVEHULFKW
S
APEL 'LH %HGHXWXQJ VWDDWOLFKHU 3ROLWLN IU GLH PRGHUQH 3ULYDWYHUVLFKHUXQJ LQ
9HUVLFKHUXQJVZLUWVFKDIW SS ± DW BÜCHNER %UDXFKHQ ZLU
HLQHQ 2PEXGVPDQQ" LQ 9HUVLFKHUXQJVZLUWVFKDIW S ± SURMINSKI
9HUVLFKHUXQJVZLUWVFKDIW XQG 9HUEUDXFKHUVFKXW] LQ =HLWVFKULIW IU 9HUVLFKHUXQJVZHVHQ
SS ± HOEREN 'HU HQJOLVFKH 9HUVLFKHUXQJV2PEXGVPDQ ± HLQ 0RGHOO
DXFK IU GLH GHXWVFKH 9HUVLFKHUXQJVZLUWVFKDIW LQ =HLWVFKULIW IU GLH JHVDPWH
9HUVLFKHUXQJVZLVVHQVFKDIW SS ± HOHLFELD hEHUOHJXQJHQ ]XU (LQIKUXQJ
HLQHV 2PEXGVPDQQV LP 9HUVLFKHUXQJVEHUHLFK LQ %DVHGRZ et al. HGV $QOHJHU
XQG REMHNWJHUHFKWH %HUDWXQJ ± 3ULYDWH .UDQNHQYHUVLFKHUXQJ ± (LQ 2PEXGVPDQQ IU
9HUVLFKHUXQJHQ%HLWUlJHGHUVLHEHQWHQ:LVVHQVFKDIWVWDJXQJGHV%XQGHVGHU9HUVLFKHUWHQ
%DGHQ%DGHQSS±
6
-UJHQ%DVHGRZWKHORQJWLPHFKDLUPDQRIWKHVXSHUYLVRU\ERDUGLVRIWKHRSLQLRQWKDW
*HUPDQ\ZDVQRWODWHEXWUDWKHUFDPHWRWKHDGRSWLRQRIWKHRPEXGVPDQSURFHGXUHDW
WKH DSSURSULDWH PRPHQW VHH BASEDOW LQ VERSICHERUNGSOMBUDSMANN E.V. HG -DKUH
9HUVLFKHUXQJVRPEXGVPDQQ±%HUOLQSSHWVHT
6HHHJREICHERT-FACILIDES, 7KH,QVXUDQFH2PEXGVPDQ$EURDG$&RPSDUDWLYH6XUYH\LQ
%DVHGRZet al.HGV$QOHJHUXQGREMHNWJHUHFKWH%HUDWXQJ±3ULYDWH.UDQNHQYHUVLFKHUXQJ
3URI'U-HQV*DO
11
PRVW QRWDEO\ LQ FRPSDULVRQ WR 6ZLW]HUODQG ZKHUH WKH 6ZLVV ,QVXUDQFH
$VVRFLDWLRQLQVWLWXWHGWKHOmbudsman der PrivatversicherungDVHDUO\DV
7KHUHDVRQVIRUWKLVGHOD\ZHUHPDQLIROG&KLHÀ\DPRQJVWWKHPZDV
WKH*HUPDQLQVXUDQFHLQGXVWU\¶VUHMHFWLRQRIDQRPEXGVPDQDVVXSHUÀXRXV
LQOLJKWWKDWDWWKHWLPHWKH*HUPDQLQVXUDQFHVXSHUYLVRU\DXWKRULW\±RWKHU
WKDQLQPDQ\RWKHUFRXQWULHV±DFWHGDVDFRPSODLQWSRLQW&DWDO\VWIRUWKH
GHYHORSPHQWRIDQRPEXGVPDQSURFHGXUHLQWKH*HUPDQLQVXUDQFHVHFWRU
ZDVWKHGHYHORSPHQWRIVXFKDPHFKDQLVPLQWKHEDQNLQJVHFWRUDWWKH
GHEXWRIWKHV10$IWHUWKH(XURSHDQ&RPPLVVLRQUHFRPPHQGHGWRDOO
0HPEHU6WDWHVWKHHVWDEOLVKPHQWRIDGLVSXWHUHVROXWLRQV\VWHPVXFKDV
HVSHFLDOO\DQRPEXGVPDQV\VWHPLQ11WKH*HUPDQEDQNLQJLQGXVWU\
LQ ± SUHVXPDEO\ DOVR LQ DQ DWWHPSW WR SUHHPSW DQ\ JRYHUQPHQW
movement on this point12 ± HVWDEOLVKHG WKH Ombudmann der privaten
Banken 2ZLQJWRWKHDOEHLWPL[HGVXSSRUWWKDWWKLVLQVWLWXWLRQJDUQHUHG
LQ WKH HQVXLQJ \HDUV14 WKH *HUPDQ LQVXUDQFH LQGXVWU\ IHOW WKH WLPH WR
±(LQ2PEXGVPDQQIU9HUVLFKHUXQJHQ%HLWUlJHGHUVLHEHQWHQ:LVVHQVFKDIWVWDJXQJGHV
%XQGHVGHU9HUVLFKHUWHQ%DGHQ%DGHQSS±
&S MAURER 2PEXGVPDQQ GHU 3ULYDWYHUVLFKHUXQJ LQ )DFXOWp GH GURLW HW GHV VFLHQFHV
pFRQRPLTXHV HW VRFLDOHV GH O¶8QLYHUVLWp GH )ULERXUJ HG 0pODQJHV HQ O¶KRQQHXU GH
+HQUL 'HVFKHQDX[ j O¶RFFDVLRQ GH VRQ VRL[DQWHGL[LqPH DQQLYHUVDLUH )ULERXUJ SS ± Y HIPPEL 'HU 2PEXGVPDQQ LP %DQN XQG 9HUVLFKHUXQJVZHVHQ ± (LQH
UHFKWVGRJPDWLVFKHXQGYHUJOHLFKHQGH8QWHUVXFKXQJ7ELQJHQSSHWVHT
MICHAELS 'LH 8QDEKlQJLJNHLW GHV 2PEXGVPDQQV LVW REHUVWHU *UXQGVDW] LQ
9HUVLFKHUXQJVZLUWVFKDIWSLORENZ'HU9HUVLFKHUXQJVRPEXGVPDQQ±HLQHQHXH
,QVWLWXWLRQLPGHXWVFKHQ9HUVLFKHUXQJVZHVHQLQ9HUVLFKHUXQJVUHFKWSS±
DWIRUDWKRURXJKKLVWRULFDORYHUYLHZYHIPPEL IQSSHWVHTT
10
SCHERPE 'HU GHXWVFKH 9HUVLFKHUXQJVRPEXGVPDQQ LQ 1HXH =HLWVFKULIW IU
9HUVLFKHUXQJVUHFKW SS ± DW D PDMRU VRXUFH RI LQVSLUDWLRQ ZDV DOVR WKH
SUH)26%ULWLVK,QVXUDQFH2PEXGVPDQ%XUHDXFIRÖMER'HU2PEXGVPDQQLPGHXWVFKHQ
3ULYDWYHUVLFKHUXQJVUHFKW LQ %DVHGRZ et al. HGV /HEHQVYHUVLFKHUXQJ ± $OWHUVYRUVRUJH
± 3ULYDWH .UDQNHQYHUVLFKHUXQJ ± 9HUVLFKHUXQJ DOV *HVFKlIWVEHVRUJXQJ ± *HQWHVW ± 'HU
2PEXGVPDQQ LP 3ULYDWYHUVLFKHUXQJVUHFKW ± %HLWUlJH ]XU :LVVHQVFKDIWVWDJXQJ GHV
%XQGHVGHU9HUVLFKHUWHQ%DGHQ%DGHQSS±DWBENKEL/HIRSCHBERGLQidem
HGV/HEHQVXQG%HUXIVXQIlKLJNHLWVYHUVLFKHUXQJQGHG0XQLFKSDUW*SDUD
11
COMMISSION5HFRPPHQGDWLRQRI)HEUXDU\RQWKHWUDQVSDUHQF\RIEDQNLQJFRQGLWLRQV
UHODWLQJWRFURVVERUGHU¿QDQFLDOWUDQVDFWLRQV((&LQ2-(&Qo/FIHVS
VL[WKSULQFLSOHLQWKHDQQH[
12
7KHUHKDGLQIDFWEHHQVRPHSUHVVXUHE\WKH)HGHUDO*RYHUQPHQWRQWKHEDQNLQJVHFWRUWR
HVWDEOLVK VXFK D GLVSXWH UHVROXWLRQ PHFKDQLVP FS GUDE 'HU 2PEXGVPDQQ GHU SULYDWHQ
%DQNHQLQ'HXWVFKODQG*UREULWDQQLHQXQGGHU6FKZHL]%RQQSSHWVHTHÖCHELQ
6FKLPDQVN\%XQWH/ZRZVNL%DQNUHFKWV+DQGEXFKthHG0XQLFKVHFSDUD
SCHERPE'HU%DQNHQRPEXGVPDQQ±=XGHQbQGHUXQJHQGHU9HUIDKUHQVRUGQXQJVHLW
LQ :0 ± =HLWVFKULIW IU :LUWVFKDIWV XQG %DQNHQUHFKW SS ± DW HOEREN 'DV QHXH 9HUIDKUHQ IU GLH 6FKOLFKWXQJ YRQ .XQGHQEHVFKZHUGHQ LP GHXWVFKHQ
%DQNJHZHUEH±*UXQG]JHXQG5HFKWVSUREOHPHLQ1HXH-XULVWLVFKH:RFKHQVFKULIW
SS±DWHWVHT
14
&IHJV. HIPPELIQSSHWVHTT
12
EH ULSH DQG LQ )HEUXDU\ WKH German Insurance Association (GDV)
GHFLGHG WKDWDQRPEXGVPDQV\VWHPZDVWREHHVWDEOLVKHG
,Q $SULO WKH German Insurance Association (GDV) IRXQGHG WKH
Versicherungsombudsmann e.V. LQ WKH IRUP RI D *HUPDQ UHJLVWHUHG
DVVRFLDWLRQ eingetragener Verein ZKLOVW HVWDEOLVKLQJ WKH DUWLFOHV RI
DVVRFLDWLRQDQGWKHRPEXGVPDQ¶VUXOHVRISURFHGXUH166XEVHTXHQWO\WKH
PHPEHUVRIWKHH[HFXWLYHERDUGRIWKHDVVRFLDWLRQZHUHFRPPLVVLRQHGDQG
Wolfgang RömerWKHIRUPHUSUHVLGHQWRIWKHLQVXUDQFHVHQDWHRIWKH*HUPDQ
BundesgerichtshofZDVHOHFWHGWREHWKH¿UVWVersicherungsombudsmann
,Q2FWREHURIWKHVDPH\HDUWKH2PEXGVPDQWRRNXSKLVZRUN,QSDUDOOHO
WRWKLVGHYHORSPHQWXQGHUWKHDHJLVRIWKHGerman Insurance Association
(GDV) WKH RWKHU *HUPDQ DVVRFLDWLRQ RI LQVXUHUV ± WKH Association of
[German] Private Healthcare Insurers (PKV)±DOVRVHWXSDQRPEXGVPDQ
V\VWHPZKLFKHTXDOO\WRRNXSLWVZRUNRQ2FWREHU
%RWK RPEXGVPDQ V\VWHPV DUH PXWXDOO\ H[FOXVLYH ZLWK WKH ODWWHU
RQO\ GHDOLQJ ZLWK GLVSXWHV DULVLQJ RXW RI SULYDWH KHDOWK RU ORQJWHUP
FDUH LQVXUDQFH FRQWUDFWV )RU WKH VDNH RI FODULW\ WKH SUHVHQW DUWLFOH ZLOO
VXEVHTXHQWO\IRFXVDOPRVWH[FOXVLYHO\RQWKHSUDFWLFDOO\PRUHLPSRUWDQW
Versicherungsombudsmann ZKLOH RQO\ VSRUDGLFDOO\ PHQWLRQLQJ WKH
2PEXGVPDQQ 3ULYDWH .UDQNHQ XQG 3ÀHJHYHUVLFKHUXQJ KHUHLQDIWHU
UHIHUUHGWRDVWKHPKV-Ombudsmann
III. Membership and Funding
3XUVXDQWWRVHFRIWKHDUWLFOHVRIDVVRFLDWLRQERWKWKHGerman Insurance
Association (GDV)DQGDOOLWVPHPEHUXQGHUWDNLQJVPD\EHFRPHPHPEHURI
LABES 'HU 2PEXGVPDQQ GHU 9HUVLFKHUXQJVZLUWVFKDIW 6DFKVWDQG ± (UZDUWXQJHQ ±
3HUVSHNWLYHQLQ%lKU/DEHV3DWDNLHGV/LEHUGLVFLSXORUXPIU*HUULW:LQWHU.DUOVUXKH
SS±DW KNAUTH'HU9HUVLFKHUXQJVRPEXGVPDQQH9±'LH(UZDUWXQJHQ
GHU 9HUVLFKHUXQJVZLUWVFKDIW LQ .ROOKRVVHU HG 'HU 9HUVLFKHUXQJVRPEXGVPDQQ H9
.DUOVUXKHSS±DWHWVHTMICHAELSIQS0LFKDHOVWKHWKHQSUHVLGHQW
RI WKH German Insurance Association (GDV) DQG ¿UVW FKDLUPDQ RI WKH H[HFXWLYH ERDUG
KRZHYHU FODLPV WKDW WKH 2PEXGVPDQ ZDV LQ LWV SUHFLVH IRUP QRW LQVSLUHG E\ DQ\ RWKHU
LQVWLWXWLRQFSMICHAELS, in: VERSICHERUNGSOMBUDSMANN E.V.HGIQS
16
BRÖMMELMEYER IQS5HJLVWUDWLRQRIWKHDVVRFLDWLRQRFFXUHGLQ0D\FIBULTMANN
'HU 9HUVLFKHUXQJVRPEXGVPDQQ H9 ± 'LH 2UJDQLVDWLRQ LQ .ROOKRVVHU HG 'HU
9HUVLFKHUXQJVRPEXGVPDQQH9.DUOVUXKHSS±DW
BULTMANN IQ S 7KH DVVRFLDWLRQ¶V VXSHUYLVRU\ ERDUG Beirat ZDV FRQVWLWXWHG LQ
)HEUXDU\
&I KALIS 'HU 2PEXGVPDQQ LQ GHU SULYDWHQ .UDQNHQYHUVLFKHUXQJ 3.9 LQ
9HUVLFKHUXQJVUHFKW SS ± V. RINTELEN LQ %HFNPDQQ0DWXVFKH%HFNPDQQ
HGV9HUVLFKHUXQJVUHFKWV+DQGEXFKQGHG0XQLFKSDUDVHWVHTT
3URI'U-HQV*DO
the Versicherungsombudsmann e.V.E\XQLODWHUDOGHFODUDWLRQRIDFFHVVLRQ
%\ EHFRPLQJ D PHPEHU RI WKH DVVRFLDWLRQ WKH LQVXUDQFH XQGHUWDNLQJV
DFFHSWWREHERXQGWRWKHUXOHVRISURFHGXUHDQGDVVXFKDJUHHWKDWWKHLU
LQVXUHGPD\SHWLWLRQWKH2PEXGVPDQ20 &XUUHQWO\WKH*'9DQGRYHU
RIDOOLQVXUDQFHXQGHUWDNLQJVHVWDEOLVKHGLQ*HUPDQ\DUHPHPEHUV212WKHU
WKDQHJLQWKH8.22 membership at the Versicherungsombudsmann e.V.
DQGDWWKHPKV-OmbudsmannLVFRPSOHWHO\YROXQWDU\
6LQFH WKH SURFHGXUH EHIRUH WKH 2PEXGVPDQ LV RIIHUHG IUHH RI FKDUJH WR
WKH FRPSODLQDQW LH WKH SROLF\KROGHU FRLQVXUHG EHQH¿FLDU\ RU RWKHU
DSSOLFDQWZKRDOOXVXDOO\QHHGWREHFRQVXPHUVWKH2PEXGVPDQDQG
LWVVXSSRUWLQJDVVRFLDWLRQQHHGWREH¿QDQFHGE\RWKHUPHWKRGVWKDQWKH
RQHV DSSOLFDEOH WR FRXUW SURFHGXUHV 7KH DVVRFLDWLRQ DQG DV VXFK WKH
GLVSXWH UHVROXWLRQ PHFKDQLVP LV ¿QDQFHG LQ D WZRIROG PDQQHU )LUVWO\
DOOPHPEHUXQGHUWDNLQJVRIWKHDVVRFLDWLRQDUHUHTXLUHGWRSD\DQDQQXDO
FRQWULEXWLRQEDVHGRQWKH¿QDQFLDOQHHGVRIWKHDVVRFLDWLRQVHFDUWLFOHV
RIDVVRFLDWLRQ7KHLQGLYLGXDOFRQWULEXWLRQRIHDFKXQGHUWDNLQJLVEDVHGRQ
LWVJURVVSUHPLXPLQFRPHLQFRPSDULVRQWRWKDWRIWKHRWKHUPHPEHUV24
6HFRQGO\ HYHU\ DGPLVVLEOH FRPSODLQW WULJJHUV D FDVHEDVHG OXPS VXP
ZKLFKWKHLQVXUDQFHXQGHUWDNLQJQHHGVWRSD\LUUHVSHFWLYHLIWKHFRPSODLQW
LVODWHUIRXQGWREHMXVWL¿HG&XUUHQWO\WKHOXPSVXPLVVHWWREH¼
LIWKHSURFHGXUHLVFRQFOXGHGE\GHFLVLRQRUQRQELQGLQJUHFRPPHQGDWLRQ
DQG¼LIWKHSURFHGXUHLVFRQFOXGHGE\DQ\RWKHUPHDQV26
3XUVXDQWWRVHFVXEVHFRIWKHDUWLFOHVRIDVVRFLDWLRQWKHPHPEHUVKLSRIDQDVVRFLDWLRQ
HQGV ¿UVWO\ de iure LI WKH XQGHUWDNLQJ ORVHV LWV PHPEHUVKLS RI WKH German Insurance
Association (GDV) RUVHFRQGO\LIWKHXQGHUWDNLQJGHFODUHVLWVUHVLJQDWLRQ
20
6HFRIWKHDUWLFOHVRIDVVRFLDWLRQ3XUVXDQWWRVXEVHFRIWKHDIRUHPHQWLRQHGSURYLVLRQ
WKHXQGHUWDNLQJVPRUHRYHUSURPLVHWRLQIRUPWKHLUFXVWRPHUVDWWKHPRPHQWRIFRQWUDFW
FRQFOXVLRQRUZLWKWKHVHQGLQJRIWKHSROLF\DERXWWKHH[LVWHQFHRIWKHGLVSXWHUHVROXWLRQ
PHFKDQLVP
21
&IV. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUDFIDOVR
OMBUDSMANN FÜR VERSICHERUNGEN-DKUHVEHULFKWSIRUDFRPSUHKHQVLYHOLVWRIWKH
PHPEHUXQGHUWDNLQJVVHHibidemSSHWVHTT
22
&I HJ RÜHL $XHUJHULFKWOLFKH 6WUHLWEHLOHJXQJ LQ 9HUVLFKHUXQJVVDFKHQ LP 9HUHLQLJWHQ
.|QLJUHLFK ± 'HU )LQDQFLDO 2PEXGVPDQ 6HUYLFH )26 LQ 1HXH =HLWVFKULIW IU
9HUVLFKHUXQJVUHFKWSS±DW
6HF VXEVHF 5XOHV RI 3URFHGXUH 2QO\ LQ WKH FDVH RI D FRPSODLQW GLUHFWHG DJDLQVW
DQ LQVXUDQFH LQWHUPHGLDU\ QRW DJDLQVW LWV HPSOR\LQJ LQVXUDQFH XQGHUWDNLQJ ZKLFK LV
PDQLIHVWO\DEXVLYHPD\WKHFRPSODLQDQWEHFKDUJHGDIHHFSVHFVXEVHFSKUDVH
UXOHVRISURFHGXUHIRUFRPSODLQWVLQFRQQHFWLRQZLWKWKHPHGLDWLRQRILQVXUDQFH
24
HIRSCH 7KH *HUPDQ ,QVXUDQFH 2PEXGVPDQ LQ =HLWVFKULIW IU GLH JHVDPWH
9HUVLFKHUXQJVZLVVHQVFKDIWSS±DW7KHPLQLPXPFRQWULEXWLRQLVVHWWR
EH¼FIOMBUDSMANN FÜR VERSICHERUNGEN IQS
HIRSCH IQS
26
OMBUDSMANN
FÜR
VERSICHERUNGEN IQS
14
IV. Organisation
$VDOUHDG\VWDWHGDERYHWKH*HUPDQLQVXUDQFHRPEXGVPDQV\VWHPZDV
HVWDEOLVKHG LQ WKH IRUP RI D SULYDWH ODZ DVVRFLDWLRQ :KLOH WKH PRVW
LPSRUWDQW IXQFWLRQ LQ FRQQHFWLRQ ZLWK WKH OHJDO SHUVRQ LV KHOG E\ WKH
2PEXGVPDQKLPVHOI±VLQFHWKHZKROHDVVRFLDWLRQ¶VUHDVRQIRUEHLQJLVWR
HQDEOHWKH2PEXGVPDQWRGRKLVZRUN±WKHRUJDQVERGLHVDQGHPSOR\HHV
RIWKHVXSSRUWLQJRUJDQLVDWLRQSOD\YLWDOUROHVDVZHOO
1. General Meeting
$VZLWKLQHYHU\*HUPDQUHJLVWHUHGDVVRFLDWLRQeingetragener VereinWKH
Versicherungsombudsmann e.V.¶VFHQWUDORUJDQLVLWVJHQHUDOPHHWLQJ7KH
JHQHUDOPHHWLQJLVPDGHXSRIDOOPHPEHUVZKLFKDOOKDYH±LUUHVSHFWLYH
RI VHL]H RU SUHPLXP LQFRPH ± D VLQJOH YRWH ZLWKLQ WKH JHQHUDO PHHWLQJ
VHFVXEVHFSKUDVH$UWLFOHVRI$VVRFLDWLRQ>VXEVHTXHQWO\UHIHUUHG
WRDV$R$@
7KHJHQHUDOPHHWLQJ¶VSDUWLFXODUFRPSHWHQFHV LQFOXGHDOWHULQJDQGDGMXVWLQJ
WKHDUWLFOHVRIDVVRFLDWLRQDQGWKHUXOHVRISURFHGXUHHOHFWLQJWKHPHPEHUV
RIWKHH[HFXWLYHERDUGHOHFWLQJFHUWDLQPHPEHUVRIWKHVXSHUYLVRU\ERDUG
DQG DSSRLQWLQJ WKH 2PEXGVPDQUHFHLYLQJ DQG FRQVXOWLQJ WKH UHSRUWVRI
WKH2PEXGVPDQDQGRIWKHH[HFXWLYHERDUGDSSURYLQJWKHDQQXDOEXGJHW
DQG GLVFKDUJLQJ WKH PHPEHUV RI WKH H[HFXWLYH ERDUG DQG WKH PDQDJLQJ
GLUHFWRUVDSSRLQWLQJDQDXGLWRUVHWWLQJXSWKHEXVLQHVVSODQDQG¿[LQJWKH
DQQXDOFRQWULEXWLRQ
7KHJHQHUDOPHHWLQJZLOOXVXDOO\PDNHXVHRILWVSRZHUVLQWKHFRXUVHRIWKH
DQQXDOJHQHUDOPHHWLQJVHF$R$:KHUHWKHLQWHUHVWVRIWKHDVVRFLDWLRQ
DUHDWVWDNHRURQH¿IWKRIWKHPHPEHUVVRUHTXHVWVWKHH[HFXWLYHERDUG
PD\ KRZHYHU DOVR FRQYHQH DQ H[WUDRUGLQDU\ JHQHUDO PHHWLQJ VHF $R$7KHDUWLFOHVRIDVVRFLDWLRQGRQRWVWLSXODWHDVSHFL¿FTXRUXP For
WKHPRVWSDUWGHFLVLRQVUHTXLUHDPHUHPDMRULW\RIWKHPHPEHUVSUHVHQW
DW WKH PHHWLQJ ZKLOH VRPH GHFLVLRQV ± LH DOWHUDWLRQ RI WKH DUWLFOHV RI
DVVRFLDWLRQRUWKHUXOHVRISURFHGXUHDSSRLQWPHQWRIWKH2PEXGVPDQDQG
H[SXOVLRQRIPHPEHUVVHFVXEVHF$R$±UHTXLUHDPDMRULW\RIWKUHH
TXDUWHUVRIWKHPHPEHUVSUHVHQW
:KLOHLWLVRQO\QDWXUDOIRUDQ\OHJDOSHUVRQWKDWWKHRZQHUVXOWLPDWHO\GHFLGH
6HHVXSUDFK,,
&SLQPRUHGHWDLOVHF$R$VHHDOVRBULTMANNIQS
*HUPDQ ODZ ± RWKHU WKDQ IRU RWKHU OHJDO SHUVRQV ± GRHV QRW LQ JHQHUDO UHTXLUH WKH
JHQHUDO PHHWLQJ RI D UHJLVWHUHG DVVRFLDWLRQ WR PHHW D VWDWXWRU\ TXRUXP FS VHF *HUPDQ&LYLO&RGH,QVRIDULWLVK\SRWKHWLFDOO\SRVVLEOHIRUDJHQHUDOPHHWLQJFRPSRVHG
RI RQH PHPEHU WR SDVV ELQGLQJ UHVROXWLRQV FS REUTER LQ 0QFKHQHU .RPPHQWDU ]XP
%UJHUOLFKHQ*HVHW]EXFKthHG0XQLFKVHFSDUD
3URI'U-HQV*DO
WKHFRXUVHRIWKHXQGHUWDNLQJLWZRXOGDSSHDU±LQWKHRU\±SUREOHPDWLFLIWKH
PHPEHUVLHWKHLQVXUDQFHXQGHUWDNLQJVZHUHWRKDYHWKHSRZHUWRHOHFW
WKH2PEXGVPDQDOWHUWKHDUWLFOHVRIDVVRFLDWLRQDQGHYHQZRUVHDOWHUWKH
UXOHVRISURFHGXUHVLQFHVXFKFRXOGFDOOLQWRTXHVWLRQWKHLQGHSHQGHQFHRI
WKHRPEXGVPDQSURFHGXUH,QDQDWWHPSWWROLPLWWKHLQVXUDQFHLQGXVWU\¶V
VZD\RYHUWKH2PEXGVPDQDQGWKHSURFHGXUHDQGDVVXFKFUHDWHPRUHWUXVW
LQWKHSURFHGXUHWKHJHQHUDOPHHWLQJ¶VSRZHUVZHUHOLPLWHGE\UHTXLULQJWKH
DSSURYDORIFHUWDLQRWKHUDFWRUVRUFUHDWLQJFRGHFLVLRQSRZHUVZKLFKZLOO
EHGLVFXVVHGDWDODWHUSRLQW7KHJHQHUDOPHHWLQJ¶VSRZHUVDUHLQVRIDUIDU
OHVVHQFRPSDVVLQJWKDQWKH\PLJKW¿UVWDSSHDU
2. Executive Board and Management
:KLOHWKHJHQHUDOPHHWLQJLVWKHVXSSRUWRUJDQLVDWLRQ¶VFHQWUDORUJDQLWV
RWKHURUJDQWKHH[HFXWLYHERDUGLVQROHVVLPSRUWDQWVLQFHLWDVVXPHVDOO
SRZHUVDQGGXWLHVZKLFKDUHQRWH[SOLFLWO\DVVLJQHGWRWKHJHQHUDOPHHWLQJ
WKHVXSHUYLVRU\ERDUGRUWKHPDQDJLQJGLUHFWRUVVHFVXEVHF$R$
7KH H[HFXWLYH ERDUG FRQVLVWV RI DW OHDVW ¿YH DQG DW PRVW PHPEHUV
VHF VXEVHF $R$ &XUUHQWO\ WKH H[HFXWLYH ERDUG FRPSULVHV HLJKW
PHPEHUV7KHPHPEHUVDUHHOHFWHGE\WKHJHQHUDOPHHWLQJIRUDWHUP
RIIRXU\HDUVZLWKUHHOHFWLRQEHLQJSRVVLEOHVHFVXEVHF$R$,WLV
LPSRUWDQWWRQRWHWKDWWKHDUWLFOHVRIDVVRFLDWLRQGRQRWDOORZIRUVRFDOOHG
Fremdorganschaft OLWHUDOO\WUDQVODWHG³H[WHUQDORUJDQVKLS´PHDQLQJWKDW
RQO\SK\VLFDOSHUVRQVWKDWDWWKHWLPHRIWKHHOHFWLRQDUHPHPEHUVRIDQ
RUJDQ RI RQH RI WKH PHPEHU XQGHUWDNLQJV DUH HOLJLEOH VHF VXEVHF SKUDVH $R$ 7KH H[HFXWLYH ERDUG HOHFWV LWV FKDLUPDQ IURP LWV PLGVW
VHFVXEVHF$R$
7KH H[HFXWLYH ERDUG¶V catchall competence LV FRPSOHPHQWHG E\ FHUWDLQ
GXWLHVDQGSRZHUVWKDWDUHH[SOLFLWO\VWDWHG0RVWLPSRUWDQWO\WKHH[HFXWLYH
ERDUG ± ZKLFK LV LWVHOI UHSUHVHQWHG E\ WZR PHPEHUV DFWLQJ FRMRLQWO\ ±
UHSUHVHQWV WKH DVVRFLDWLRQ WR WKH RXWVLGH 7KH H[HFXWLYH ERDUG LV DOVR
FRPSHWHQWWRUHFRPPHQGWKHSHUVRQWREHHOHFWHGDV2PEXGVPDQGH¿QH
9HU\ FULWLFDO RQ WKHVH SRLQWV TIFFE (LQHLQKDOE -DKUH 9HUVLFKHUXQJVRPEXGVPDQQ H9 LQ
9HUEUDXFKHUXQG5HFKWSS±DWHWVHT
,QWHUHVWLQJO\ HQRXJK WKHVH WZR DUH SXUVXDQW WR VHF $R$ WKH RQO\ RUJDQV RI WKH
Versicherungsombudsmann e.V.,QVRIDUQHLWKHUWKH2PEXGVPDQQRUPRUHVXUSULVLQJO\
WKHERDUGRIVXSHUYLVRUVDUHUHJDUGHGDVRUJDQV
OMBUDSMANN
FÜR
VERSICHERUNGEN IQSS
&SVHFVXEVHFOLWD$R$LQFRQQHFWLRQZLWKVHFVXEVHF$R$$OOFXUUHQWPHPEHUV
VDYH WZR DUH FKDLUPHQ RI WKH H[HFXWLYH ERDUGV RI HPLQHQW *HUPDQ LQVXUHUV 7KH WZR
H[FHSWLRQVDUHFrank von FürstenwerthWKHFKDLUPDQRIWKHGerman Insurance Association
(GDV)DQGGutberletZKRLVDPHPEHU±DQGQRWWKHFKDLUPDQ±RIWKHH[HFXWLYHERDUG
RI$OOLDQ]
16
WKHVFRSHRIFRPSHWHQFHRIWKH2PEXGVPDQDVORQJDVVXFKWDVNLVQRW
UHVHUYHG IRU WKH JHQHUDO PHHWLQJ DQG WKH VXSHUYLVRU\ ERDUG UHFDOO DQ
2PEXGVPDQZKHUHVXFKZDVDJUHHGE\WKHVXSHUYLVRU\ERDUGSUHSDUH
DQG FRQYRNH JHQHUDO PHHWLQJV LPSOHPHQW WKH GHFLVLRQV RI WKH JHQHUDO
PHHWLQJSUHSDUHDEXVLQHVVSODQDQG¿QDOO\DSSRLQWVXSHUYLVHDQGUHFDOO
PDQDJLQJGLUHFWRUVVHFVXEVHF$R$
7KHFXUUHQWRSHUDWLRQVRIWKHDVVRFLDWLRQDUHDVVXPHGE\WKHPDQDJLQJ
GLUHFWRU $V PHQWLRQHG EHIRUH LW LV IRU WKH H[HFXWLYH ERDUG WR DSSRLQW
RQHRUVHYHUDOPDQDJLQJGLUHFWRUV7KLVPDQDJLQJGLUHFWRULVERXQGE\
WKH VWDWXWHV IRU PDQDJLQJ GLUHFWRUV HVWDEOLVKHG E\ WKH H[HFXWLYH ERDUG
VHF VXEVHF $R$ &XUUHQWO\ ± VLQFH ± WKLV RI¿FH LV DVVXPHG
E\ Horst Hiort ,W LV XVXDOO\ KH ZKR SUHSUHSDUHV WKH SUHSDUDWLRQ RI
JHQHUDO PHHWLQJV LPSOHPHQWDWLRQ RI GHFLVLRQV RI WKH JHQHUDO PHHWLQJ
DQGSUHSDUDWLRQRIDEXVLQHVVSODQ+HLVPRUHRYHUUHVSRQVLEOHIRUKLULQJ
DQGVXSHUYLVLQJWKHHPSOR\HHVDQGIRURUJDQLVLQJWKHZKROHGD\WRGD\
RSHUDWLRQVRIWKHDVVRFLDWLRQ
3. Supervisory Board
2QH RI WKH PRVW GD]]OLQJ IHDWXUHV RI WKH 2PEXGVPDQ¶V VXSSRUWLQJ
RUJDQLVDWLRQLVLWVVXSHUYLVRU\ERDUG7KRXJKQRWDQRUJDQSURSHURIWKH
DVVRFLDWLRQ WKH VXSHUYLVRU\ ERDUG VHUYHV DQ LPSRUWDQW UROH LQ PDNLQJ
FHUWDLQ WKDW WKH 2PEXGVPDQ FDQ VHUYH KLV IXQFWLRQ XQKDUDVVHG E\ WKH
LQVXUDQFH LQGXVWU\ DQG WKDW WKH SURFHGXUH UHPDLQV IDLU DQG EDODQFHG
7KH VXSHUYLVRU\ ERDUG LV LQVRIDU WKH JXDUDQWRU RI WKH 2PEXGVPDQ¶V
LQGHSHQGHQFHDQGDVVXFKWKHJXDUDQWRURIWKHSURFHGXUH¶VVXFFHVVZLWK
WKHJHQHUDOSXEOLF
7KHVXSHUYLVRU\ERDUGFRQVLVWVRIPHPEHUVVHYHQUHSUHVHQWDWLYHVRI
WKHPHPEHUXQGHUWDNLQJVDPRQJVWZKLFKWKHFKDLUPDQRIWKHH[HFXWLYH
ERDUG VHYHQ UHSUHVHQWDWLYHV RI FRQVXPHU SURWHFWLRQ RUJDQLVDWLRQV
WZR UHSUHVHQWDWLYHV RI WKH *HUPDQ ,QVXUDQFH 6XSHUYLVRU %D)LQ WZR
UHSUHVHQWDWLYHVRILQVXUDQFHPHGLDWRURUJDQLVDWLRQVWKUHHUHSUHVHQWDWLYHV
RIWKHVFLHQWL¿FZRUOGDQGVL[UHSUHVHQWDWLYHVRIWKHSDUOLDPHQWDU\IUDFWLRQV
$PRQJVWWKHVHRQO\WKHUHSUHVHQWDWLYHVRIWKHPHPEHUXQGHUWDNLQJVDUH
OMBUDSMANN
FÜR
VERSICHERUNGEN IQSS
6WDII PHPEHUV ZKR DUH FKDUJHG ZLWK WDVNV UHODWLQJ WR WKH FRPSODLQWV KDQGOLQJ DUH
KRZHYHUXQGHUWKHWHFKQLFDOVXSHUYLVLRQLQFOXGLQJDSRZHUWRJLYHLQVWUXFWLRQVRIWKH
2PEXGVPDQVHHVHFVXEVHF$R$
&SVHF VXEVHF$R$VHHDOVR OMBUDSMANN
IQS
FÜR
VERSICHERUNGEN IQ SHIRSCH
See sec. 6 AOAFSDOVRVXSUDIQ
:LWKDFRPSDUDEOHLQWHUSUHWDWLRQHIRSCHIQSYHU\FULWLFDORIWKLVDVVHVVPHQW
TIFFE IQSZKRFODLPVWKHVXSHUYLVRU\ERDUGWREHOLWWOHPRUHWKDQD¿JOHDYH
3URI'U-HQV*DO
HOHFWHGE\WKHJHQHUDOPHHWLQJZKLOHWKHUHSUHVHQWDWLYHVRIWKHVFKRODVWLF
ZRUOGDUHHOHFWHGZLWKDWZRWKLUGPDMRULW\RIDOOPHPEHUVRIWKHFXUUHQW
VXSHUYLVRU\ ERDUG DQG DOO RWKHU UHSUHVHQWDWLYHV DUH GHOHJDWHG E\ WKH
UHVSHFWLYH LQVWLWXWLRQ :KDW LV REYLRXV IURP WKLV FRPSRVLWLRQ LV WKDW WKH
LQVXUDQFH XQGHUWDNLQJV¶ LQÀXHQFH RYHU WKH VXSHUYLVRU\ ERDUG DQG LWV
GHFLVLRQVLVHYHU\WKLQJEXWFRPPDQGLQJ
7KH WDVNV HQWUXVWHG WR WKH VXSHUYLVRU\ ERDUG LQFOXGH DV IROORZV FR
UHVSRQVLELOLW\ LQ WKH DSSRLQWPHQW DQG UHFDOOLQJ RI WKH 2PEXGVPDQ FR
UHVSRQVLELOLW\ IRU WKH DOWHUDWLRQ RI WKH SURFHGXUDO UXOHV ULJKW WR D VD\ RQ
WKH QRPLQDWLRQ RI WKH PDQDJLQJ GLUHFWRU ULJKW WR UHFHLYH DQG FRQVXOW WKH
UHSRUWVRIWKH2PEXGVPDQULJKWWRPDNHUHFRPPHQGDWLRQVWRLPSURYHWKH
2PEXGVPDQ¶VZRUNDQGWKHSURFHGXUDOUXOHVULJKWWRPDNHUHFRPPHQGDWLRQV
IRU WKH DJHQGD RI JHQHUDO PHHWLQJV DQG ULJKW WR FRXQVHO DQG DLG WKH
2PEXGVPDQFRQFHUQLQJTXHVWLRQVRISXEOLFUHODWLRQVHFVXEVHF$R$
'HFLVLRQVDUHWDNHQXQOHVVRWKHUZLVHSURYLGHGZLWKDPDMRULW\RIYRWHVRI
WKHPHPEHUVSUHVHQWVHFVXEVHFSKUDVH$R$
,QGLVFKDUJLQJRILWVGXWLHVWKHVXSHUYLVRU\ERDUGPDNHVDODUJHFRQWULEXWLRQ
LQNHHSLQJWKH2PEXGVPDQLQGHSHQGHQWDQGWKHSURFHGXUHHIIHFWLYHDQG
IDLU 2QH VKRXOG LQVRIDU QRWH WKDW WKH SRZHUV DQG WKH FRPSRVLWLRQ RI
WKHVXSHUYLVRU\ERDUGDUHIRUWKHPRVWSDUWLQWHQGHGWRNHHSLQFKHFNWKH
LQÀXHQFH RI WKH LQVXUDQFH XQGHUWDNLQJV DQG DV VXFK WKDW RI WKHLU PDLQ
UHSUHVHQWDWLYH RUJDQ WKH JHQHUDO PHHWLQJ 7KLV HTXLOLEUDWLQJ HIIHFW RI
WKHVXSHUYLVRU\ERDUGFDQEHVHHQIRUH[DPSOHLQLWVFRUHVSRQVLELOLW\LQ
QRPLQDWLQJ WKH 2PEXGVPDQ ,I VXFK D SRZHU ZHUH QRW SURYLGHG E\ WKH
DUWLFOHVRIDVVRFLDWLRQQRWKLQJZRXOGSURFHGXUDOO\NHHSWKHJHQHUDOPHHWLQJ
LHWKHLQVXUDQFHXQGHUWDNLQJVIURPQRPLQDWLQJDSHUVRQDV2PEXGVPDQ
ZKRPWKH\NQRZWREHH[FHVVLYHO\LQVXUHUIULHQGO\DQGWKXVWXUQLQJWKH
ZKROHSURFHGXUHLQWRDIDUFH7KHVDPHDSSOLHVIRUWKHFRUHVSRQVLELOLW\LQ
PRGLI\LQJWKHSURFHGXUDOUXOHV,IVXFKSRZHUZDVH[FOXVLYHO\HQWUXVWHGWR
WKHJHQHUDOPHHWLQJ±DVLWZRXOGEHLQWKHFDVHRIDQRUGLQDU\UHJLVWHUHG
DVVRFLDWLRQ ± WKH LQVXUDQFH XQGHUWDNLQJV ZRXOG EH DEOH WR PDQLSXODWH
WKHSURFHGXUDOUXOHVWRIDYRXUWKHPXQGXO\7KHFRGHFLVLRQSRZHURIWKH
VXSHUYLVRU\ERDUGLVLQVRIDUDQHWHUQDOJXDUDQWHHIRUWKHSURFHGXUDOUXOHV
WRDWOHDVWUHPDLQDVIDLUDVWKH\ZHUHGUDIWHGDWWKHWLPHRIWKHIRUPDWLRQ
RIWKHRPEXGVPDQRI¿FH
4. Ombudsman
7KH FHQWUDO LQVWLWXWLRQ ZLWKLQ WKH Versicherungsombudsmann e.V. ± DQG
its sole raison d’être±LVWKH2PEXGVPDQLHWKHSHUVRQHQWUXVWHGZLWK
OMBUDSMANN FÜR VERSICHERUNGEN IQSUHJDUGVWKHVXSHUYLVRU\ERDUG±DQGLWVFRPSRVLWLRQ
HVSHFLDOO\WKHIDFWWKDWLWFRQWDLQVUHSUHVHQWDWLYHVRIFRQVXPHUSURWHFWLRQRUJDQLVDWLRQV
±DVRQHRIWKHPRVWGLVWLQJXLVKLQJIHDWXUHVRIWKHVersicherungsombudsmann
WKHSRZHUWRDGMXGLFDWHGLVSXWHVEHWZHHQWKHPHPEHUXQGHUWDNLQJVDQG
LWVFXVWRPHUV40
,Q RUGHU WR FUHDWH WUXVW ZLWK WKH SXEOLF ZKLFK PLJKW EH XQGHUVWDQGDEO\
VXVSLFLRXVRIDGLVSXWHUHVROXWLRQPHFKDQLVP¿QDQFHGE\WKHRSSRVLQJSDUW\
WKHVXFFHVVRIWKHSURFHGXUHWXUQVRQWKHTXDOLW\RIWKHSHUVRQQRPLQDWHG
DV2PEXGVPDQ41,QKLVSHUVRQDQGDFWLRQVKHVKRXOGLIVXFKLVSRVVLEOH
EHDPDQLIHVWDWLRQRI/RUG+HZDUW¶VGLFWXPWKDW³MXVWLFHVKRXOGQRWRQO\EH
GRQHEXWVKRXOGPDQLIHVWO\DQGXQGRXEWHGO\EHVHHQWREHGRQH´422WKHU
WKDQWKLVRXWHUDSSHDUDQFHRILQGHSHQGHQFHDQGDFWXDOLQGHSHQGHQFHWKH
DUWLFOHVRIDVVRFLDWLRQUHTXLUHWKH2PEXGVPDQWRPHHWVHYHUDOSHUVRQUHODWHG
FULWHULD+HLVUHTXLUHGWRSRVVHVVWKHQHFHVVDU\DELOLWLHVTXDOL¿FDWLRQVDQG
H[SHULHQFHIRUKLVWDVNVVHFVXEVHFSKUDVH$R$,QSDUWLFXODUKH
VKRXOGEHTXDOL¿HGWRH[HUFLVHWKHIXQFWLRQVRIDMXGJHZKLFKLQ*HUPDQ\
PHDQV KH PXVW QRW RQO\ KDYH REWDLQHG D XQLYHUVLW\ GHJUHH LQ ODZ EXW
DOVRVXFFHVVIXOO\SHUIRUPHGWKHReferendariat >IRUPRIFOHUNVKLS@DQGWKH
VHFRQGVWDWH¶VH[DPDQGSRVVHVVVSHFLDOH[SHULHQFHLQLQVXUDQFHPDWWHUV
VHFVXEVHFSKUDVH$R$+HIXUWKHUPRUHVKRXOGKDYHKLVOHJDO
UHVLGHQFHLQ*HUPDQ\440RUHLPSRUWDQWO\WKH2PEXGVPDQPD\QRWKDYH
ZRUNHGRQDIXOOWLPHEDVLVIRUDQLQVXUDQFHXQGHUWDNLQJRUDQLQVXUDQFH
OREE\LQJRUJDQLVDWLRQRUDVDQLQVXUDQFHLQWHUPHGLDU\RULQVXUDQFHDGYLVHU
GXULQJ WKH WKUHH \HDUV WKDW SUHFHGH KLV DFFHVVLRQ WR WKH RI¿FH VHF VXEVHFSKUDVH$R$
The Versicherungsombudsmann e.V. ZDVOXFN\HQRXJKWR¿QGMXVWWKHPDQ
40
&RQFHUQLQJWKHUHODWLRQVKLSEHWZHHQWKH2PEXGVPDQDQGWKHVXSSRUWLQJRUJDQL]DWLRQLW
VHHPVIHDVLEOHWRUHJDUGWKHIRUPHUDVWKHVSHFLDOUHSUHVHQWDWLYHUHJDUGLQJDGMXGLFDWLRQ
RIGLVSXWHVLQWKHVHQVHRIVHF*HUPDQ&LYLO&RGHRIWKHODWWHULQWKLVVHQVHLORENZ
'HU9HUVLFKHUXQJVRPEXGVPDQQ±HLQHQHXH,QVWLWXWLRQLPGHXWVFKHQ9HUVLFKHUXQJVZHVHQ
LQ9HUVLFKHUXQJVUHFKWSS±DW
41
RÖMER LV RI FRXUVH FRUUHFW LQ VWDWLQJ WKDW WKH SHUVRQDOLW\ RI WKH 2PEXGVPDQ FDQ QHYHU
EHVXI¿FLHQWWRPDNHXSIRULQVWLWXWLRQDOGH¿FLWV FLWHGLQ BRÖMMELMEYER%HULFKWEHUGLH
'LVNXVVLRQ ]XP 9RUWUDJ YRQ )ULW] 5HLFKHUW)DFLOLGHV LQ %DVHGRZ et al. HGV $QOHJHU
XQG REMHNWJHUHFKWH %HUDWXQJ ± 3ULYDWH .UDQNHQYHUVLFKHUXQJ ± (LQ 2PEXGVPDQQ IU
9HUVLFKHUXQJHQ%HLWUlJHGHUVLHEHQWHQ:LVVHQVFKDIWVWDJXQJGHV%XQGHVGHU9HUVLFKHUWHQ
%DGHQ%DGHQSS±DW
42
H.C. (King¶s Bench)5H[Y6XVVH[-XVWLFHV>@.%DWSHU/RUG+HZDUW&-
)URPWKHZRUGLQJRIWKHSURYLVLRQLWLVQRWFRPSOHWHO\FOHDULIWKLVUHTXLUHPHQWLVFRPSXOVRU\
VLQFHWKHSKUDVHDSSOLHVWKH*HUPDQZRUG³soll´GHSHQGLQJRQWKHFRQWH[WWKLVPD\PHDQ
shall or oughtLQVWHDGRIWKHOHVVDPELJXRXVZRUG³muss´*HUPDQIRUVKDOORUPXVWLQ
WKH¿UVWSKUDVHRIWKLVVHFWLRQ
44
$JDLQLWLVXQFOHDULIWKLVLVFRPSXOVRU\RULIWKHQRPLQDWLQJDFWRUVDUHDOORZHGWRPDNHDQ
H[FHSWLRQFSVXSUDIQ
:KLOH WKHVH FULWHULD UHJDUG RQO\ TXDOLWLHV EHIRUH WKH DVVXPSWLRQ RI WKH GXWLHV RI
WKH 2PEXGVPDQ VHF VXEVHF $R$ VHWV RXW FHUWDLQ GXWLHV GXULQJ WKH WHUP 7KH
2PEXGVPDQPXVWUHIUDLQIURPWDNLQJRQDQ\RIWKHMREVHQXPHUDWHGDERYHDQGPXVWDOVR
UHIUDLQIURPDQ\DFWLYLW\WKDWPLJKWFDOOLQWRTXHVWLRQKLVLQGHSHQGHQFH
3URI'U-HQV*DO
WR¿WWKLVSUR¿OHDQGLQHOHFWHGWolfgang RömerWKHIRUPHUSUHVLGHQW
RI WKH LQVXUDQFH VHQDWH RI WKH *HUPDQ Bundesgerichtshof DV LWV ¿UVW
2PEXGVPDQ46'LVDSSURYLQJWKHSURYHUEWKDWOLJKWQLQJQHYHUVWULNHVWZLFH
the Versicherungsombudsmann e.V. ZDVDEOHWRUHSODFH3URI5|PHU±ZKHQ
KHYDFDWHGWKHRI¿FHLQ±ZLWKDQHTXDOO\GLVWLQJXLVKHGLQVXUDQFHODZ
H[SHUW3URI*QWKHU+LUVFK+LUVFKDIRUPHUMXGJHRIWKH(XURSHDQ&RXUW
RI-XVWLFHDQGWKHIRUPHUSUHVLGHQWRIWKH*HUPDQBundesgerichtshofZDV
HOHFWHGLQDQGLVVWLOODFWLQJDV2PEXGVPDQ7KHH[WUDRUGLQDU\OHYHO
RIOHJDOH[SHUWLVHDQGUHSXWDWLRQRIWKHVHSHUVRQDOLWLHVKDVEHHQSDUDPRXQW
LQHVWDEOLVKLQJWKHRPEXGVPDQSURFHGXUHLQWKHH\HVRISROLF\KROGHUVDVD
YLDEOHDOWHUQDWLYHIRUWKHUHVROXWLRQRIGLVSXWHVZLWKWKHLULQVXUHUV
%HVLGHVWKHLQGLYLGXDORI¿FHKROGHU¶VZLOOLQJQHVVWRDFWLQGHSHQGHQWO\RWKHU
VDIHJXDUGVDUHQHFHVVDU\WRJXDUDQWHHWKH2PEXGVPDQ¶VLQGHSHQGHQFH
2QH RI WKH PRVW LPSRUWDQW SURFHGXUDO VDIHJXDUGV LV HQVKULQHG LQ WKH
QRPLQDWLRQSURFHGXUH7KH2PEXGVPDQLVQRWVLQJOHKDQGHGO\HOHFWHGE\
D VSHFL¿F RUJDQ RI WKH VXSSRUWLQJ DVVRFLDWLRQ EXW WKURXJK D FRGHFLVLRQ
SURFHVV 7KH ULJKW RI LQLWLDWLYH LV YHVWHG LQ WKH H[HFXWLYH ERDUG ZKRVH
GXW\LWLVWRUHFRPPHQGDSHUVRQWREHHOHFWHGDV2PEXGVPDQVHFF
VXEVHFOLWEVXEVHF$R$,WLVWKHQIRUWKHVXSHUYLVRU\ERDUGWR
WDNHDGHFLVLRQ±ZLWKDPDMRULW\RIWKHYRWHVRIWKHPHPEHUVSUHVHQW±RQ
ZKHWKHURUQRWWRHOHFWWKHSHUVRQUHFRPPHQGHGVHFFVXEVHFOLWE
VXEVHF$R$)LQDOO\WKHJHQHUDOPHHWLQJPD\DSSRLQW±ZLWKDWKUHH
TXDUWHUPDMRULW\RIDOOPHPEHUVSUHVHQWVHFVXEVHF$R$±WKH
SHUVRQLQTXHVWLRQWRWKHRI¿FHVHFFOLWEVXEVHF$R$7KURXJK
WKLVSURFHGXUHLWLVPDGHFHUWDLQWKDWRQO\DSHUVRQJDUQHULQJVXSSRUWIURP
DOOLQWHUHVWHGFLUFOHVPD\EHHOHFWHG2PEXGVPDQ
2QFHWKH2PEXGVPDQWDNHVXSKLVRI¿FHKHLVERXQGE\DGXW\DQGJUDQWHGD
JXDUDQWHHRILQGHSHQGHQFH7KLVJXDUDQWHHRILQGHSHQGHQFHHQFRPSDVVHV
KLVGHFLVLRQVKLVGLUHFWLRQVRIWKHSURFHHGLQJVDQGKLVDGPLQLVWUDWLRQRI
WKHRI¿FHDVDZKROHVHFVXEVHFSKUDVH$R$0RUHSUHFLVHO\KH
LVXQGHUQRGXW\WRFRPSO\ZLWKDQ\LQVWUXFWLRQVDQGQRRUJDQRUERG\RI
WKHVXSSRUWLQJDVVRFLDWLRQPD\JLYHVXFKLQVWUXFWLRQV
46
BULTMANN IQS,IDQ\WKLQJ5|PHUZDVUHJDUGHGE\VRPHLQVXUHUVDVSROLF\KROGHU
ELDVHGEXWFHUWDLQO\QRRQHZRXOGKDYHWKRXJKWKLPWREHSDUWLDOWRZDUGVWKHLQVXUHU¶V
LQWHUHVWFSMICHAELSLQVERSICHERUNGSOMBUDSMANN E.V.HGIQS
3URI+LUVFKZDVUHHOHFWHGLQDQGKLVVHFRQGDQGODVWWHUPKDVFRPPHQFHGLQ$SULO
7KDW VXFK DQ LQVWLWXWLRQDO VDIHJXDUG IRU LQGHSHQGHQFH LV QHFHVVDU\ FDQ EH VHHQ E\ WKH
FULWLFLVPDWWUDFWHGE\IRUPHU*HUPDQ%DQN2PEXGVPDQ/HR3DUVFK'XHWRWKHIDFWRI
KDYLQJ EHHQ QRPLQDWHG VROHO\ E\ WKH LQGXVWU\ ± DV ZDV SURYLGHG IRU E\ WKH DUWLFOHV RI
DVVRFLDWLRQ ± KH ZDV RIWHQ GHFULHG DV D ³KRPH UHIHUHH´ ZKR DGMXGLFDWHG E\ ¿DW ³nach
Gutsherrenart´FSV. HIPPELIQSSZLWKIXUWKHUUHIHUHQFHV
20
7KHLQGHSHQGHQFHRIWKH2PEXGVPDQLVDOVRVDIHJXDUGHGE\WKHIDFWWKDWWKH
2PEXGVPDQPD\RQO\XQGHUYHU\VWULFWFRQGLWLRQVEHGLVPLVVHGIURPRI¿FH
)LUVWO\RQO\ÀDJUDQWDQGJURVVEUHDFKHVRIWKH2PEXGVPDQ¶VVWDWXWRU\RU
contractualGXWLHVPD\VHUYHDVJURXQGVIRUGLVPLVVDOVHFVXEVHF
SKUDVH $R$ 6HFRQGO\ LQ RUGHU IRU WKH 2PEXGVPDQ WR EH GLVPLVVHG
WKHUHQHHGVWREHDGHFLVLRQWRWKLVHQGQRWRQO\E\WKHH[HFXWLYHERDUG
EXWDOVRE\WKHQHXWUDOVXSHUYLVRU\ERDUGDQGWKHODWWHU¶VGHFLVLRQQHHGV
WREHFDUULHGE\DWZRWKLUGVPDMRULW\RIDOOPHPEHUVVHFVXEVHF
SKUDVH LQ FRQQHFWLRQ ZLWK VHF VXEVHF OLW D $R$ ,QWHUHVWLQJO\
HQRXJK DQRWKHU VDIHJXDUG IRU WKH 2PEXGVPDQ¶V LQGHSHQGHQFH ZDV
SUHYLRXVO\SURYLGHGE\WKHDUWLFOHVRIDVVRFLDWLRQEXWZDVDEDQGRQHGLQ
8SXQWLOWKDWWLPHWKHWHUPRIRI¿FHZDV±DQGVWLOOLV±IRUXSWR¿YH
\HDUVEXWUHHOHFWLRQZDVGLVDOORZHGVHFVXEVHF$R$YHUVLRQ
7KHH[FOXVLRQRIDSRVVLELOLW\WREHUHHOHFWHGZDVLQWHQGHGWRDYRLGWKH
DSSHDUDQFHWKDWWKH2PEXGVPDQPLJKWEHVZD\HGWRDOWHUKLVGHFLVLRQVLQ
DZD\WRPDNHKLVUHHOHFWLRQPRUHOLNHO\,QKRZHYHUWKHJHQHUDO
PHHWLQJYRWHGLQDPRGL¿FDWLRQRIWKHDUWLFOHVRIDVVRFLDWLRQREYLRXVO\LQ
DQDWWHPSWWREHDEOHWRNHHSWKHWKHQ2PEXGVPDQ3URI5|PHURQIRU
DQDGGLWLRQDOSHULRGRIWLPHDOORZLQJIRUDRQHWLPHUHHOHFWLRQVHF
VXEVHFSKUDVH$R$,QOLJKWRIWKHIDFWWKDWWKH2PEXGVPDQ±LIKH
ZHUHWRWU\WRLQÀXHQFHKLVUHHOHFWLRQGHFLVLRQ±ZRXOGKDYHWRSDQGHUWR
WKHLQWHUHVWVRIWKHLQVXUHUVDQGWRWKDWRIWKHSROLF\KROGHUVDWWKHVDPH
WLPHVLQFHKHQHHGVWREHUHHOHFWHGE\DOOERGLHVRIWKHDVVRFLDWLRQRQH
FDQVHHZK\WKLVVDIHJXDUGZDVVHHQDVVXSHUÀXRXV7KH2PEXGVPDQ¶V
LQGHSHQGHQFHLVDPSO\SURWHFWHGE\RWKHUPHDQV
5. Other Employees
:LWK DQ DQQXDO FDVH ORDG RI RYHU FRPSODLQWV DQG EHLQJ EXW RQH
SHUVRQ±VLQFHWKHDUWLFOHVRIDVVRFLDWLRQDOORZRQO\IRUWKHHOHFWLRQRID
VLQJOHSHUVRQWRDFWDV2PEXGVPDQ±WKH2PEXGVPDQPXVWKHDYLO\UHO\
RQWKHDVVLVWDQFHRIDX[LOLDU\VWDII2WKHUWKDQWKH2PEXGVPDQDQGWKH
5HJDUGLQJWKHVHUYLFHFRQWUDFWZKLFKWKH2PEXGVPDQFRQFOXGHVZLWKWKHDVVRFLDWLRQ
)RU WKH ROG YHUVLRQ RI WKH DUWLFOHV RI DVVRFLDWLRQ VHH HJ 1HXH =HLWVFKULIW IU
9HUVLFKHUXQJVUHFKWSS±
BULTMANN IQ SS HW VHT 7KDW WKLV LV QRW D PHUHO\ K\SRWKHWLFDO SUREOHP PD\ EH
KLJKOLJKWHGE\WKHIDFWWKDWWKHIRUPHU2PEXGVPDQRIWKH(QJOLVK,QVXUDQFH2PEXGVPDQ
%XUHDX -XOLDQ )HUUDQG FRPSODLQHG WKDW VRPH LQVXUHUV KDG DOOHJHGO\ WULHG WR LQÀXHQFH
WKH ,2% &RXQFLO WR QRW UHHOHFW KLP LQ YLHZ RI KLV RYHUO\ FRQVXPHUIULHQGO\ GHFLVLRQV
FSV. HIPPELIQSSZLWKIXUWKHUUHIHUHQFHV
VERSICHERUNGSOMBUDSMANN E.V.HGIQS
7KLV ZDV GLIIHUHQWO\ XQGHU WKH ¿UVW YHUVLRQ RI WKH DUWLFOHV RI DVVRFLDWLRQ ZKHUH VHF VXEVHF$R$DOORZHGIRUWKHHOHFWLRQRIVHYHUDORPEXGVPHQFS$R$UHSULQWHG
LQ1HXH=HLWVFKULIWIU9HUVLFKHUXQJVUHFKWSS±DW
3URI'U-HQV*DO
21
PDQDJLQJGLUHFWRUWKHVXSSRUWLQJDVVRFLDWLRQFXUUHQWO\HPSOR\VDQRWKHU
SHUVRQV2IWKHVHSHRSOHVWDIIPHPEHUVDUHWUDLQHGLQWKHLQVXUDQFH
EXVLQHVV Versicherungskaufmann DQG DUH WKH LQWHJUDO SDUW RI WKH VR
FDOOHG VHUYLFH FHQWUH 7KHLU WDVNV FRQVLVW LQ UHJLVWHULQJ WKH FRPSODLQWV
FUHDWLQJWKHFDVH¿OHKHOSLQJWKHFRPSODLQDQWVLQFRQFUHWLVLQJWKHLUFODLPV
DQGLQJHQHUDOPDNLQJWKHFDVHUHDG\IRUOHJDOVFUXWLQ\EHIRUHWXUQLQJWKH
FDVHRYHUWRWKHOHJDOFHQWUHRUGHFLGLQJRQLWVLQDGPLVVLELOLW\
7KH OHJDO FHQWUH HPSOR\V SHUVRQV ZKR DUH ODZ\HUV Volljuristen
LH SHRSOH TXDOL¿HG WR H[HUFLVH WKH IXQFWLRQV RI D MXGJH 7KHVH SHRSOH
FRUUHVSRQG ZLWK DQ HPSKDVLV RQ OHJDO PDWWHUV ZLWK DOO SDUWLHV LQ DQ
DWWHPSWWRPDNHWKHFDVHUHDG\IRUGHFLVLRQWKH\VRXQGRXWWKHSRVVLELOLW\
RI DQ DPLFDEOH DUUDQJHPHQW DQG WKH\ RIWHQ ± WKH 2PEXGVPDQ FRXOG
QRWSHUVRQDOO\DGMXGLFDWHFDVHV±WDNHWKHGHFLVLRQVRQEHKDOIRI
WKH2PEXGVPDQ&DVHVRIJUHDWHULPSRUWDQFHRUZLWKPRUHSUREOHPDWLF
EHDULQJDUHKRZHYHURIWHQGHFLGHGE\WKH2PEXGVPDQLQSHUVRQ
7KHUHVWRIWKHVWDIIRIWKHVXSSRUWRUJDQLVDWLRQLVHPSOR\HGIRUVHFUHWDULDO
RUDGPLQLVWUDWLYHZRUN
V. Jurisdiction
7KH2PEXGVPDQKDVMXULVGLFWLRQRYHUDYDVWDUUD\RIGLVSXWHVWKRXJKQRW
RYHU DOO GLVSXWHV WKDW PD\ DULVH EHWZHHQ D SROLF\KROGHU RU LQVXUHG RU
EHQH¿FLDU\DQGKLVLQVXUHUDQGLQVXUDQFHLQWHUPHGLDULHV,WLVLPSRUWDQW
WR QRWH WKDW WKH WHUP MXULVGLFWLRQ VKRXOG QRW EH XQGHUVWRRG WR PHDQ
H[FOXVLYH FRPSHWHQFH VLQFH WKH SUHVXPDEO\ DJJULHYHG SDUW\ LV DW DQ\
VWDJHIUHHWREULQJLWVFODLPEHIRUHWKHFRPSHWHQWVWDWHFRXUWRUDUELWUDO
WULEXQDOZKHUHVXFKDSSOLHV,WLVWKH2PEXGVPDQ¶VGXW\WRHVWDEOLVKDW
WKHPRPHQWDWZKLFKWKHFRPSODLQWLVORGJHGDQGFRQWLQXRXVO\WKURXJKRXW
WKHFRXUVHRIWKHSURFHHGLQJVLILWLVFRPSHWHQWWRKHDUWKHFODLPVHF
VXEVHF5XOHVRI3URFHGXUH
,QGRLQJVRWKH2PEXGVPDQPXVWHVWDEOLVKLIWKHFRPSODLQDQWIXO¿OVWKH
SHUVRQUHODWHGUHTXLUHPHQWVWRKDYHVWDQGLQJWRORGJHDFRPSODLQWLIWKH
UHVSRQGHQWKDVWKHVWDQGLQJWREHPDGHVXFKLIWKHVXEMHFWPDWWHURIWKH
OMBUDSMANN
FÜR
VERSICHERUNGEN IQS
6HHLQPRUHGHWDLOLQIUDFK9,DQG
,QDOORWKHUFDVHVWKH2PEXGVPDQKDVDSRZHUWRLQVWUXFWWKHODZ\HUVIXUWKHUPRUHWKH
ODZ\HUVZLOOEHREOLJDWHGWRUHQGHUFHUWDLQGHFLVLRQVIRUDSSURYDOEHIRUHEHLQJUHQGHUHG
DQGZLOOLQPRUHJHQHUDOWHUPVEHXQGHUWKHFRQVWDQWVXSHUYLVLRQRIWKH2PEXGVPDQFS
OMBUDSMANN FÜR VERSICHERUNGEN IQSSHWVHT
Argumentum e contrario VHF VXEVHF OLW H 5R3 ZKLFK GHFODUHV WKH RPEXGVPDQ
SURFHGXUHQRWWRWDNHSODFHLIWKHFRPSODLQDQWSHWLWLRQVWKHFRXUWVGXULQJWKHRPEXGVPDQ
SURFHHGLQJV
22
GLVSXWHHQWHUVLQWRWKHFRPSHWHQFHRIWKH2PEXGVPDQLIWKHFRPSODLQDQW
KDV FRPSOLHG ZLWK WKH SURFHGXUDO UHTXLUHPHQWV LI DQ H[FHSWLRQ WR WKH
MXULVGLFWLRQRIWKH2PEXGVPDQPLJKWDSSO\DQG¿QDOO\LIWKH2PEXGVPDQ
VKRXOGUHMHFWWKHFRPSODLQWRQJURXQGVRILWEHLQJXQVXLWDEOHIRUDGMXGLFDWLRQ
ZLWKLQWKHRPEXGVPDQSURFHGXUH
1. Person-Related Requirements
7KHRPEXGVPDQSURFHGXUHLVRQO\DYDLODEOHZKHUHERWKFRPSODLQDQWDQG
UHVSRQGHQW IXO¿O WKH SHUVRQUHODWHG FULWHULD UHTXLUHG WR KDYH VWDQGLQJ
EHIRUHWKH2PEXGVPDQ
a) Complainant
3XUVXDQWWR VHFVXEVHFF DQG$R$LW LV WKHVXSSRUWRUJDQLVDWLRQ¶V
FRUSRUDWH SXUSRVH ³WR DGYDQFH WKH DOWHUQDWLYH UHVROXWLRQ RI GLVSXWHV
EHWZHHQ LQVXUDQFH XQGHUWDNLQJV DQG FRQVXPHUV SROLF\KROGHUV´ ,W LV
LQVRIDUQRVXUSULVHWKDWWKHSURFHGXUHLVLQSULQFLSOHRQO\PDGHDYDLODEOH
ZKHUHWKHFRPSODLQDQWLVDFRQVXPHUVHFVXEVHFSKUDVH5XOHVRI
3URFHGXUH>VXEVHTXHQWO\UHIHUUHGWRDV5R3@7KHODWWHUSURYLVLRQGH¿QHV
DFRQVXPHUWREHDQDWXUDOSHUVRQZKRHQWHUVLQWRDOHJDOWUDQVDFWLRQIRU
DSXUSRVHWKDWLVRXWVLGHKLVWUDGHEXVLQHVVRUSURIHVVLRQ
:KLOH WKH EHDULQJ RI WKLV SURYLVLRQ LV FOHDU LQ WKDW RQO\ FRPSODLQWV E\
natural persons KDYLQJ WKH VWDWXV RI FRQVXPHU DUH DGPLVVLEOH LW
FUHDWHV VRPH XQFHUWDLQW\ LI RQO\ SROLF\KROGHUV PD\ ORGJH D FRPSODLQW60
8QGHU WKH DSSOLFDWLRQ RI WKH ROG UXOHV RI SURFHGXUH RQH FRXOG PDNH D
VWURQJ DUJXPHQW WR WKLV HIIHFW VLQFH LWV SUHDPEOH GHFODUHG WKDW Ä>W@KH
9HUVLFKHUXQJVRPEXGVPDQQ LV DQ LQGHSHQGHQW LQVWLWXWLRQ RI WKH *HUPDQ
LQVXUDQFH LQGXVWU\ IRU WKH UHFRQFLOLDWLRQ RI GLVSXWHV EHWZHHQ LQVXUDQFH
XQGHUWDNLQJVDQGFRQVXPHUVSROLF\KROGHUV>«@´61$VWULFWUHDGLQJRIWKLV
SURYLVLRQ ZRXOG KDYH KHQFH H[FOXGHG WKH FRLQVXUHG DQG WKH EHQH¿FLDU\
IURP PDNLQJ XVH RI WKH RPEXGVPDQ SURFHGXUH 7KLV ZDV KRZHYHU QRW
7KLVGH¿QLWLRQLVDGLUHFWWUDQVIRUPDWLRQRIWKHJHQHUDOGH¿QLWLRQRIFRQVXPHUVLQVHF
*HUPDQ&LYLO&RGH
7KH*HUPDQFLYLOODZDVVRFLDWLRQGesellschaft bürgerlichen Rechts >GBR@±WKRXJKLWPD\
VXHLQLWVSURSHUQDPH±LVQRWDOHJDOSHUVRQEXWDXQLRQRIQDWXUDOSHUVRQV,QVRIDU
WKHUHLVDJRRGDUJXPHQWWREHPDGHWKDWLILWVDVVRFLDWHVDUHQDWXUDOSHUVRQVDQGWKH
GbR¶VSXUSRVHIRUHQWHULQJLQWRWKHWUDQVDFWLRQLVRXWVLGHLWVWUDGHEXVLQHVVRUSURIHVVLRQ
LWLVDVXLWDEOHFRPSODLQDQWFSHÖVELLQ+DOP(QJHOEUHFKW.UDKHHGV+DQGEXFKGHV
)DFKDQZDOWV9HUVLFKHUXQJVUHFKWthHG&RORJQHFKSDUD
60
7KLVSUREOHPRILQWHUSUHWDWLRQEHFRPHVPRUHSUHVVLQJVLQFHVHFVXEVHFOLWG5R3
H[SOLFLWO\GHFODUHVDVLQDGPLVVLEOHDQ\FRPSODLQWUHJDUGLQJWKHFODLPRID³WKLUGSDUW\´WR
WKHLQVXUDQFHEHQH¿WVVHHLQIUDFK9G
61
5R3UHSULQWHGLQ1HXH=HLWVFKULIWIU9HUVLFKHUXQJVUHFKWSS±DW
3URI'U-HQV*DO
D UHDGLQJ IDYRXUHG ± HYHQ DW WKDW WLPH ± E\ WKH PDMRULW\ RI VFKRODUV62
6LQFH WKH SUHDPEOH ZDV VXEVHTXHQWO\ DOWHUHG ± WR QRZ UHDG WKDW ³Ä>W@KH
9HUVLFKHUXQJVRPEXGVPDQQ LV DQ LQGHSHQGHQW LQVWLWXWLRQ RI WKH *HUPDQ
LQVXUDQFH LQGXVWU\ IRU WKH UHFRQFLOLDWLRQ RI GLVSXWHV LQ FRQQHFWLRQ ZLWK
LQVXUDQFH FRQWUDFWV´ ± WKHUH QRZ VHHPV WR EH D XQLYHUVDO XQGHUVWDQGLQJ
WKDWWKHFRLQVXUHGEHQH¿FLDULHVDQGOHJDOVXFFHVVRUVUHVSDVVLJQHHVDUH
DOVRLQSULQFLSOHSHUPLWWHGDVFRPSODLQDQWV7KHDGPLVVLELOLW\RIFRPSODLQWV
ORGJHGE\WKHVHSHRSOHLVKRZHYHUFRQWLQJHQWRQWKHLUDELOLW\WRLQGLYLGXDOO\
GHPDQGSHUIRUPDQFHXQGHUWKHLQVXUDQFHFRQWUDFW,QFDVHRIDFRPSODLQW
E\ D FRLQVXUHG IRU H[DPSOH WKLV UHTXLUHV WKDW WKH FRLQVXUHG LV HLWKHU
LQ SRVVHVVLRQ RI WKH LQVXUDQFH SROLF\ RU LV DFWLQJ ZLWK WKH SROLF\KROGHU¶V
DSSURYDOVHFVXEVHF*HUPDQ,QVXUDQFH&RQWUDFW$FW64
7KHIXOOH[FOXVLRQRIDOOQRQFRQVXPHUVIURPWKHSURFHGXUHZDVUHJDUGHGE\
PDQ\DVDPLVWDNH7KHVHVFKRODUVKDYHFRQWLQXRXVO\DGYRFDWHGWKHLQFOXVLRQ
RIVXFKSHUVRQVWKDWPD\EHUHJDUGHGDVFRQVXPHUOLNH,QUHDFWLRQWRWKLV
FULWLFLVPWKHUXOHVRISURFHGXUHZHUHDPHQGHGLQ7KH\QRZH[SOLFLWO\
SURYLGH LQ VHF VXEVHF SKUDVH WKDW WKH 2PEXGVPDQ ³may KDQGOH
FRPSODLQWV E\ WUDGHVPHQ LI WKHLU WUDGH LV SXUVXDQW WR LWV W\SH VL]H DQG
LQIUDVWUXFWXUHWR EH FRQVLGHUHG D VPDOO WUDGH >Kleingewerbe@´ >HPSKDVLV
DGGHG@,QVRIDUVPDOOWUDGHUV±ZKLFKDUHFRQVLGHUHGFRQVXPHUOLNH±PD\
QRZSHWLWLRQWKH2PEXGVPDQ7KHLUSRVLWLRQDVDGPLVVLEOHFRPSODLQDQWV
VHHPVWREHDOLWWOHELWZHDNHUKRZHYHUVLQFHWKHXWLOL]DWLRQRIWKHYHUE
³PD\´LQWKHDERYHSURYLVLRQLPSOLHVWKDWWKH2PEXGVPDQHQMR\VDFHUWDLQ
DPRXQWRIGLVFUHWLRQLQDGPLWWLQJRUUHMHFWLQJRQHRIWKHLUFODLPV$OORWKHU
WUDGHVPHQDQGSURIHVVLRQDOVPD\QRWSHWLWLRQWKH2PEXGVPDQ66,QWKLV
FRQWH[WLWLVLPSRUWDQWWRFRUUHFWO\DVVHVVLIDVSHFL¿FLQVXUDQFHFRQWUDFW
ZDVWDNHQRXWIRUEXVLQHVVRUIRUSULYDWHSXUSRVHVHJFDULQVXUDQFHIRU
DYHKLFOHXVHGERWKIRUSULYDWHDQGEXVLQHVVSXUSRVHV
62
&SHJHÖVEL/LEISSNERLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUDVHWVHTT
RÖMER2IIHQHXQGEHDQWZRUWHWH)UDJHQ]XP9HUIDKUHQYRUGHP2PEXGVPDQQLQ1HXH
=HLWVFKULIW IU 9HUVLFKHUXQJVUHFKW SS ± DW UHJDUGLQJ EHQH¿FLDULHV
HÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUDVHWVHTT
64
HÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD)RUPRUHGHWDLOVHHLQIUD
FK9
&I Y HIPPEL IQ S. 214; SCHERPE IQ S LORENZ IQ S RÖMER 'HU
2PEXGVPDQQ IU SULYDWH 9HUVLFKHUXQJHQ LQ 1HXH -XULVWLVFKH :RFKHQVFKULIW SS±DW
66
)RU DQ XQSXEOLVKHG GHFLVLRQ RI WKH 2PEXGVPDQ VHH HÖVEL LQ +DOP(QJHOEUHFKW.UDKH
HGVIQFKSDUD
7KH¿UVW2PEXGVPDQSRLQWHGWRWKHGHFLVLRQ%*+=FRQFHUQLQJWKHGHPDUFDWLRQ
EHWZHHQSULYDWHDQGEXVLQHVVUHODWHGDFWLYLWLHVVHHRÖMERIQS
24
b) Respondent
7KH FRPSODLQW PXVW EH GLUHFWHG DJDLQVW DQ LQVXUDQFH XQGHUWDNLQJ ZKLFK
LVDPHPEHURIWKHVersicherungsombudsmann e.V&RPSODLQWVDJDLQVW
QRQPHPEHUXQGHUWDNLQJVDUHLPSHUPLVVLEOH7KHXWLOLVDWLRQRIWKHWHUP
³LQVXUDQFH XQGHUWDNLQJ´ LV QRW LQWHQGHG WR H[FOXGH FRPSODLQWV DJDLQVW
RFFXSDWLRQDOSHQVLRQIXQGV$VORQJDVWKH\DUHPHPEHUVRIWKHVXSSRUW
RUJDQLVDWLRQ±ZKLFKRQO\YHU\IHZDUH±WKH\KDYHWKHVWDQGLQJWREHD
UHVSRQGHQWLQWKHSURFHGXUH
6LQFHWKH2PEXGVPDQLVDOVRFRPSHWHQWWRKHDUFRPSODLQWVDJDLQVW
LQVXUDQFHLQWHUPHGLDULHVLHLQVXUDQFHDJHQWVDQGLQVXUDQFHEURNHUVDQG
LQVXUDQFHFRQVXOWDQWV7KHVXSSRUWRUJDQLVDWLRQZDVHQWUXVWHGZLWKWKLV
WDVNE\WKH)HGHUDO0LQLVWU\RI-XVWLFHDQGLWDOWHUHGLWVDUWLFOHVRIDVVRFLDWLRQ
DQGHQDFWHGGLVWLQFWUXOHVRISURFHGXUHWRGHDOZLWKVXFKGLVSXWHV7KH
SURFHGXUH LV GLVWLQFW WR WKH RQH DSSOLHG WR FRPSODLQWV DJDLQVW LQVXUDQFH
XQGHUWDNLQJV GHVFULEHG KHUH LQ WKDW WKH LQVXUDQFH PHGLDWRU GRHV QRW
QHHGWREHLQIDFWFDQQRWEHDPHPEHURIWKHVXSSRUWRUJDQLVDWLRQDQG
LQ WKDW WKH 2PEXGVPDQ¶V DGMXGLFDWLRQ PD\ QHYHU WDNH RQ WKH IRUP RI D
ELQGLQJGHFLVLRQEXWZLOODOZD\VEHDPHUHUHFRPPHQGDWLRQ,QOLJKWRI
WKH UDWKHU UHGXFHG SUDFWLFDO VLJQL¿FDQFH RI FRPSODLQWV DJDLQVW LQVXUDQFH
PHGLDWRUV±LQWKH\PDGHXSURXJKO\WZRSHUFHQWRIDOOFRPSODLQWV
±WKHSUHVHQWWUHDW\ZLOOKHQFHIRUWKIRFXVH[FOXVLYHO\RQFRPSODLQWVDJDLQVW
LQVXUDQFHXQGHUWDNLQJV
)RUDOLVWRIWKHPHPEHUXQGHUWDNLQJVVHHOMBUDSMANN FÜR VERSICHERUNGEN-DKUHVEHULFKW
SSHWVHTT
HÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUDDOVRFRUUHFWO\SRLQWVRXW
WKDWWKHPHPEHUVKLSRIDQLQVXUHUDWZKLFKWKHSHQVLRQIXQGVPLJKWKDYHEHHQLQVWLWXWHG
LVLQVXI¿FLHQW7KHSHQVLRQIXQGVLWVHOIQHHGVWREHDPHPEHU
,QJHQHUDOXQFHUWDLQW\DVWRWKHPHPEHUVKLSRIDQXQGHUWDNLQJPD\DULVHZKHUHQRWLWEXW
WKHFRQFHUQWRZKLFKLWEHORQJVKDVGHFODUHGLWVDFFHVVLRQWRWKHVXSSRUWDVVRFLDWLRQ+HUH
RQHKDVWRLQWHUSUHWWKHGHFODUDWLRQRIDFFHVVLRQZKHWKHURUQRWLWLQFOXGHVDOOGDXJKWHU
FRPSDQLHVFSRÖMERIQS
See HIRSCH IQSBRÖMMELMEYER IQSIQ
ANONYMUSLQ)'9HUV5>Qo@
6HHKWWSZZZYHUVLFKHUXQJVRPEXGVPDQQGH1DYLJDWLRQVEDXP9HUP9RMVS
6LQFHWKHUHLVQHYHUDQ\ELQGLQJHIIHFWLWZDVVHHQ¿WQRWWROLPLWWKHDPRXQWLQGLVSXWHXS
XQWLOZKLFKWKH2PEXGVPDQPD\KHDUDFODLPVHHHIRSCH IQS,QWKLVUHVSHFW
DOVRWKHSURFHGXUHLVGLVWLQFWIURPWKHRQHUHJDUGLQJFODLPVDJDLQVWLQVXUHUVVHHLQIUD
FK9D
7KH UHDVRQ IRU WKLV FDQ EH VHHQ LQ WKH IDFW WKDW UHJDUGLQJ LQVXUDQFH LQWHUPHGLDULHV WKH
RPEXGVPDQ SURFHGXUH LV QRW YROXQWDU\ EXW UDWKHU SUHVFULEHG E\ VWDWXWH D VWDWXWRU\
RPEXGVPDQSURFHGXUHZKLFKIRUFHVDWOHDVWRQHRIWKHSDUWLHVWRSDUWLFLSDWHDQGUHQGHUV
ELQGLQJ GHFLVLRQV LV KRZHYHU LQ *HUPDQ\ UHJDUGHG DV D YLRODWLRQ RI WKH FRQVWLWXWLRQDO
ULJKWWRWKHODZIXOMXGJHFSV. HIPPELIQSSHWVHT
OMBUDSMANN
FÜR
VERSICHERUNGEN-DKUHVEHULFKWS
3URI'U-HQV*DO
2. Subject Matter within the Ombudsman’s Jurisdiction
7KH2PEXGVPDQLVRQO\FRPSHWHQWWRKHDUGLVSXWHVWKDWUHJDUGDQRZQ
FRQWUDFWXDOFODLPRIWKHFRPSODLQDQWDULVLQJRXWRIDQLQVXUDQFHFRQWUDFW
RUDQRWKHUFRQWUDFWZKLFKGLVSOD\VDQLQWULFDWHHFRQRPLFFRQQHFWLRQZLWK
DQLQVXUDQFHFRQWUDFWVHFVXEVHFSKUDVHOLWD5R3)URPWKLVLW
IROORZV WKDW VXFK SHUVRQV LQYRNLQJ D FODLP IRU GDPDJHV RU KDYLQJ D VR
FDOOHGGLUHFWFODLPFSVHF*HUPDQ,QVXUDQFH&RQWUDFW$FWZKLFKLV
DGHULYDWLYHRIWKHSROLF\KROGHU¶VFODLPRXWRIWKHLQVXUDQFHFRQWUDFWPD\
QRWSHWLWLRQWKH2PEXGVPDQ7KLV±LQSDUWLFXODU±H[FOXGHVVXFKFODLPV
UDLVHGE\WKHLQMXUHGSDUW\LQDFDUDFFLGHQWIURPEHLQJDGMXGLFDWHGZLWKLQ
WKHRPEXGVPDQV\VWHP
7KHUHVWLOOUHPDLQVVRPHGRXEWZKHWKHUWKHFULWHULRQ³RZQFODLP´KDVVRPH
IXUWKHUOLPLWDWLYHEHDULQJ:KLOHLWVHHPVHYLGHQWWKDWDEHQH¿FLDU\DQGD
FRLQVXUHGZRXOGQRWEHH[FOXGHGE\WKLVSKUDVHGRXEWPD\DULVHFRQFHUQLQJ
D SHUVRQ WR ZKLFK WKH SROLF\KROGHU KDV FRQWUDFWXDOO\ DVVLJQHG KLV FODLP
(YHQ PRUH LPSRUWDQWO\ LW UDLVHV WKH TXHVWLRQ ZKHWKHU WKH SROLF\KROGHU
KLPVHOILVH[FOXGHGIURPEULQJLQJDFODLPEHIRUHWKH2PEXGVPDQZKHUH
VXFKFODLPLVVXEMHFWWRDQLQVXUDQFHIRUWKHDFFRXQWRIDQRWKHU:KLOHVXFK
DFODLPLVLQWKHVWULFWVHQVHQRWKLVRZQWRGLVDOORZWKHSROLF\KROGHUWR
EULQJ WKH FODLP ZRXOG VHHP LQHTXLWDEOH 8QGHU PDQ\ JHQHUDO WHUPV DQG
FRQGLWLRQVWKHLQVXUHGLVH[FOXGHGIURPGLUHFWO\UDLVLQJDFODLPDJDLQVWWKH
LQVXUHU (YHQ LI QR VXFK FRQWUDFWXDO H[FOXVLRQ H[LVWV WKH LQVXUHG LV RQO\
DOORZHGWRPDNHDGLUHFWFODLPZKHQLQSRVVHVVLRQRIWKHLQVXUDQFHSROLF\
RU DFWLQJ ZLWK WKH DSSURYDO RI WKH SROLF\KROGHU ,Q JHQHUDO LW LV IRU WKH
SROLF\KROGHUWRGLVSRVHRIWKHFODLPLQKLVSURSHUQDPHVHFVXEVHF
*HUPDQ,QVXUDQFH&RQWUDFW$FW,WZRXOGWKXVEHPRVWUHDVRQDEOH±DQG
such appears to be the practice±WRDOORZFODLPVRIWKHFRLQVXUHGWREH
PXWXDOO\H[FOXVLYHO\EURXJKWHLWKHUE\WKHFRLQVXUHGLIKHLVLQSRVVHVVLRQ
RIWKHSROLF\RUDFWLQJZLWKDSSURYDORUE\WKHSROLF\KROGHU
Prima facia LW PLJKW VXUSULVH WKDW WKH 2PEXGVPDQ LV HTXDOO\ FRPSHWHQW
WR KHDU FODLPV DULVLQJ IURP RWKHU FRQWUDFWV WKDQ LQVXUDQFH FRQWUDFWV
6XFK FRQWUDFWV PXVW KRZHYHU H[KLELW D FORVH HFRQRPLF FRQQHFWLRQ WR
DQLQVXUDQFHFRQWUDFW,WPXVW¿UVWO\EHQRWHGWKDWWKLVH[WHQVLRQLVQRW
PHDQWWREULQJWKLUGSDUW\UHVSRQGHQWVLQWRWKHIROG±WKHFODLPRXWRIWKH
6RPHVFKRODUVKDYHIRUZDUGHGWKHLGHDWRLQFOXGHVXFKFODLPVVHHHJSCHERPE IQ
S +RZHYHU VLQFH WKH RPEXGVPDQ V\VWHP LV ZLGHO\ UHJDUGHG E\ WKH LQGXVWU\ DV D
VSHFLDOVHUYLFHIRUWKHLUFXVWRPHUVVHHHJKNAUTH9HUVLFKHUXQJVRPEXGVPDQQ±SULYDWH
6WUHLWEHLOHJXQJ IU 9HUEUDXFKHU LQ :0 ± =HLWVFKULIW IU :LUWVFKDIWV XQG %DQNHQUHFKW
SS±DW>IQ@VXFKLVUDWKHUXQOLNHO\WRRFFXULQWKHQHDUIXWXUH
6HHDOUHDG\WKHGRXEWVRIWKH¿UVW2PEXGVPDQLQRÖMERIQS
6HHVXSUDFK9D
RÖMERIQS
26
FRQQHFWHGFRQWUDFWPXVWEHDJDLQVWDPHPEHUXQGHUWDNLQJ2WKHUZLVHLW
UHPDLQV GLI¿FXOW WR DVVHVV ZKLFK NLQG RI FRQWUDFW GLVSOD\V WKH QHFHVVDU\
LQWHUFRQQHFWHGQHVVWRDQLQVXUDQFHFRQWUDFWWREHHQFRPSDVVHGE\VHF
VXEVHF SKUDVH OLW D 5R3 6XFK D FRQWUDFW PLJKW IRU H[DPSOH EH DQ
LQGHSHQGHQWFRQVXOWDQF\DJUHHPHQWFRQFOXGHGDWWKHWLPHRIWKHFRQFOXVLRQ
RIWKHLQVXUDQFHFRQWUDFW1RWHQFRPSDVVHGZRXOGEHDORDQDJUHHPHQW
HYHQLIWKHORDQLVLQWHQGHGWREHSDLGRIIE\DOLIHLQVXUDQFHFRQWUDFWVLQFH
WKLVFRQQHFWLRQLVQRWUHJDUGHGDVFORVHHQRXJK
3XUVXDQW WR VHF VXEVHF SKUDVH OLW E 5R3 WKH FRPSODLQW PD\
IXUWKHUPRUH UHJDUG FODLPV DULVLQJ DJDLQVW DQ LQVXUDQFH XQGHUWDNLQJ LQ
FRQQHFWLRQ ZLWK WKH PHGLDWLRQ RU SUHFRQWUDFWXDO QHJRWLDWLRQ RI VXFK
FRQWUDFWVDVHQFRPSDVVHGE\VHFVXEVHFSKUDVHOLWD5R3
3. Compliance with Procedural Requirements
8QGHUWKHROGUXOHVRISURFHGXUHDFRPSODLQWZDVRQO\SHUPLVVLEOHLIWKH
FRPSODLQDQWORGJHGKLVFRPSODLQWZLWKLQHLJKWZHHNVDIWHUKDYLQJUHFHLYHG
WKHLQVXUHU¶V¿QDOGHFODUDWLRQ7KLVUXOHRIVHFVXEVHFOLWD5R3
±ZKLFKZDVDNLQWRDVSHFLDOSHULRGRIOLPLWDWLRQ±ZDVKRZHYHUZLWKJRRG
UHDVRQDEGLFDWHGLQ
7KHRQO\SURFHGXUDOUHTXLUHPHQWWKDWQHHGVWREHIXO¿OOHGLQDGYDQFHIRU
DFODLPWREHKHDUGLVSURYLGHGE\VHFVXEVHF5R33XUVXDQWWRVDLG
SURYLVLRQWKH2PEXGVPDQPD\RQO\KHDUDFRPSODLQWDIWHUDFRPSODLQDQW
KDVUDLVHGVXFKFRPSODLQWDJDLQVWWKHXQGHUWDNLQJLQTXHVWLRQDQGJLYHQ
WKH LQVXUHU VL[ ZHHNV WLPH WR WDNH D ¿QDO GHFLVLRQ 7KLV UHTXLUHPHQW LV
LQWHQGHG WR JLYH WKH LQVXUHU DPSOH WLPH DQG RSSRUWXQLW\ WR UHVROYH DQ\
GLVSXWH LWVHOI EHIRUH EHLQJ GUDJJHG EHIRUH WKH 2PEXGVPDQ ,QVRIDU
7KLV GRHV LQ FRQWUDVW QRW PHDQ WKDW DOO FRQWUDFWV FRQFOXGHG ZLWK PHPEHU XQGHUWDNLQJV
PHHWWKHWKUHVKROG±LQDQXQSXEOLVKHGGHFLVLRQWKH2PEXGVPDQGHFOLQHGKLVMXULVGLFWLRQ
WR KHDU D FODLP RXW RI D ORDQ DJUHHPHQW FRQFOXGHG EHWZHHQ WKH FRPSODLQDQW DQG DQ
LQVXUDQFHXQGHUWDNLQJVLQFHWKHUHZDVQRFRQQHFWLRQWRDQLQVXUDQFHFRQWUDFWVHHHÖVEL
LQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD
RÖMERIQS
RÖMER IQ S WKH DVVHVVPHQW PLJKW EH GLIIHUHQW IRU D VRFDOOHG SROLF\ ORDQ
Policendarlehen ZKLFK LV IXOO\ ¿QDQFHG RXW RI D OLIH LQVXUDQFH FRQWUDFW VHH HÖVEL LQ
+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD
7KLVLVQRWEHFRQIXVHGZLWKFODLPVGLUHFWHGDJDLQVWWKHLQVXUDQFHLQWHUPHGLDULHVZKLFK
DUHDGMXGLFDWHGXQGHUGLIIHUHQWSURFHGXUDOUXOHVVHHVXSUDIQ,QVXUDQFHDJHQWVDQG
LQVXUDQFH XQGHUWDNLQJV ZLOO RIWHQ EH MRLQWO\ DQG VHYHUDOO\ OLDEOH XQGHU *HUPDQ ODZ FS
VHF*HUPDQ,QVXUDQFH&RQWUDFW$FW
7KHUHZDVDQH[FHSWLRQWRWKLVUXOHZKHUHWKHEHODWHGORGJLQJRIWKHFODLPZDVQRWFDXVHG
E\WKHSROLF\KROGHU¶VIDXOWVHHVHFVXEVHFOLWD5R3UHSULQWHGLQ1HXH=HLWVFKULIW
IU9HUVLFKHUXQJVUHFKWSS±DW
)RUVRPHGLI¿FXOWTXHVWLRQVWKDWWKLVUXOHUDLVHGVHH RÖMERIQSSHWVHT
See V. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUDHÖVELLQ
3URI'U-HQV*DO
WKH FRPSODLQW PD\ UHJDUG WZR GLVWLQFW YDULDQWV HLWKHU WKH FRPSODLQDQW
LVXQKDSS\ZLWKWKHGHFLVLRQWDNHQE\WKHLQVXUHURULWZLVKHVWRKDYHD
GHFLVLRQZKLFKWKHLQVXUHUKDVQRWLVVXHGZLWKLQWKHVL[ZHHNVWLPHSHULRG
%RWKNLQGVRIFRPSODLQWDUHDGPLVVLEOH
4. Exclusions from Jurisdiction
)RUYDULRXVUHDVRQVVRPHFODLPVDUHH[FOXGHGIURPWKHMXULVGLFWLRQRIWKH
2PEXGVPDQ6XFKH[FOXVLRQVPD\EHIRXQGLQVHFVXEVHF5R3DQG
ZLOOEHDGGUHVVHGVXEVHTXHQWO\
a) Amount in Dispute (lit. a)
,QDQDSSDUHQWDWWHPSWWROLPLWWKH2PEXGVPDQ¶VFDVHORDGDQGWRUHVHUYH
¿QDQFLDOO\PRUHLPSRUWDQWGLVSXWHVWRWKHFRXUWVWKHUXOHVRISURFHGXUH
KDYHVLQFHWKHLUHQDFWPHQWSURYLGHGIRUDQH[FHVVDPRXQWLQGLVSXWH$Q\
FRPSODLQWLQZKLFKWKLVDPRXQWLVH[FHHGHGLVLQDGPLVVLEOH,QWKLV
DPRXQWZDVVHWDW¼ZDVHOHYDWHGWR¼LQDQG¿QDOO\
WR¼LQ:KLOHWKLVFXUUHQWDPRXQWPD\DSSHDUJHQHURXV
HQRXJKLQFRPSDULVRQWRVRPHRWKHURPEXGVPDQSURFHGXUHVLWFHUWDLQO\
FDXVHVVRPHSUREOHPVLHHVSHFLDOO\WKDWFHUWDLQLIQRWWKHWRWDOLW\RI
FODLPVSHUWDLQLQJWRSURIHVVLRQDOGLVDELOLW\LQVXUDQFHDQGDFFLGHQWLQVXUDQFH
DUH V\VWHPDWLFDOO\ UHPRYHG IURP WKH DXWKRULW\ RI WKH 2PEXGVPDQ
&RQVLGHULQJWKDWDQ\³GHFLVLRQÉ\WKH2PEXGVPDQUHJDUGLQJDQDPRXQWLQ
H[FHVVRI¼ZRXOGWDNHWKHIRUPRIDQRQELQGLQJUHFRPPHQGDWLRQ
RQHFRXOGWDNHWKHSRVLWLRQWKDWLWZRXOGQRWFDXVHWKHLQVXUHUDQ\KDUPWR
VXEPLWDOOFDVHVQRPDWWHUZKDWWKHDPRXQWLQGLVSXWHWRWKH2PEXGVPDQ¶V
MXULVGLFWLRQ2QWKHFRQWUDU\LWVHHPVTXLWHUHDVRQDEOHWKDWWKHLQVXUDQFH
XQGHUWDNLQJVRQO\UHQGHUVXFKGLVSXWHVUHJDUGLQJWKHDPRXQWLQGLVSXWH
WR WKH MXULVGLFWLRQ RI WKH 2PEXGVPDQ ZLWK ZKLFK WKH\ IHHO FRQ¿GHQW WR
EHDEOHWRDGKHUHWRWKHUHFRPPHQGDWLRQLQWKHPDMRULW\RIFDVHV7KHUH
PLJKWEHDQDPRXQWLQGLVSXWHZKHUHVRPHLQVXUHUVZRXOGDVDJHQHUDO
+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD
&SV. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUD
SCHERPE IQSYLHZVWKLVDVDQLOOXVWUDWLRQWKDWWKHLQVXUDQFHLQGXVWU\KDGWRROLWWOH
IDLWKLQLWV³RZQ´GLVSXWHUHVROXWLRQRUJDQL]DWLRQ
V.
RINTELEN LQ %HFNPDQQ0DWXVFKH%HFNPDQQ HGV IQ SDUD LV FRUUHFW LQ
DVFHUWDLQLQJWKDWWKLVH[FHVVDPRXQWLQGLVSXWHLVELQGLQJDQGWKDWWKHSDUWLHVPD\QRW
DJUHHDVWRLWVLQDSSOLFDELOLW\,WLVWKHH[FOXVLYHSUHURJDWLYHRIWKH2PEXGVPDQWRDVVHVV
H[RI¿FLRLIWKHH[FHVVDPRXQWLQGLVSXWHLVH[FHHGHG
&SVERSICHERUNGSOMBUDSMANN E.V.HGIQSSHWVHT
7KRXJK LW VKRXOG EH QRWHG WKDW LQ WKH UXOHV RI SURFHGXUH IRU FODLPV DJDLQVW LQVXUDQFH
LQWHUPHGLDULHVQRVXFKH[FHVVDPRXQWLQGLVSXWHH[LVWVWKHVWDWXWHVZKLFKLQFRUSRUDWHWKH
UXOHVRISURFHGXUHRIWKHPKV-OmbudsmannGRHTXDOO\QRWSURYLGHIRUVXFKDOLPLWDWLRQ
see V. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUD
UXOHEHXQZLOOLQJWRVHWWOHWKHFODLPDPLFDEO\LIQRWIRUFHGE\DFRXUWRI
ODZ+HUHWKHRPEXGVPDQSURFHGXUHZRXOGEHFRPHPRRWVLQFHLWZRXOG
RQO\SRVWSRQHWKHLQHYLWDEOH,QWKLVOLJKWWKHH[FHVVDPRXQWLQGLVSXWHRI
¼DSSHDUVWREHQRWIXOO\XQUHDVRQDEOH
,WLVPRUHGLI¿FXOWWRDVVHVVKRZWKLVDPRXQWLQGLVSXWHLVWREHFDOFXODWHG
,Q WKLV FRQWH[W WKH UXOHV RI SURFHGXUH H[SODLQ WKDW WKH 2PEXGVPDQ LV
WR DSSO\ WKH SULQFLSOHV RI WKH *HUPDQ &RGH RI &LYLO 3URFHGXUH UHJDUGLQJ
WKH DPRXQW LQ GLVSXWH In concreto WKLV ZRXOG IRU H[DPSOH PHDQ WKDW D
FRPSODLQWUHJDUGLQJDFODLPIRUWKHSD\PHQWVRIEHQH¿WVHJ¼
ZRXOG KDYH DQ DPRXQW LQ GLVSXWH HTXDO WR WKH DPRXQW RI WKH FODLPHG
EHQH¿WVLH¼,IWKHFRPSODLQWUHJDUGVWKHULJKWWRDQDQQXLW\
WKHDPRXQWLQGLVSXWHLVSXUVXDQWWRVHFSKUDVH*HUPDQ&RGHRI&LYLO
3URFHGXUHWKHDPRXQWRIWKHDQQXLW\PXOWLSOLHGE\WKUHHDQGDKDOI:KLOH
WKHJHQHUDOUXOHVRISURFHGXUHFRQFHUQLQJWKHFDOFXODWLRQRIWKHDPRXQWLQ
GLVSXWHVLQVRIDUDSSO\±XQOHVVWKH\QHHGWREHDGDSWHGGXHWRWKHVSHFL¿F
QDWXUH RI WKH RPEXGVPDQ SURFHGXUH ± WKHUH LV RQH PDQLIHVW H[FHSWLRQ
6HFVXEVHFOLWD5R3H[SOLFLWO\SURYLGHVWKDWWKHDPRXQWLQGLVSXWH
RIDFRPSODLQWZKLFKUHYHDOVWKDWLWUHJDUGVRQO\DSDUWRIWKHIXOOFODLP
offengelegte Teilbeschwerde LV HTXDO WR WKH DPRXQW LQ GLVSXWH RI WKH
IXOO FODLP 7KLV UXOH ZDV LQFOXGHG LQWR WKH UXOHV RI SURFHGXUH LQ RUGHU
WR SUHYHQW SROLF\KROGHUV IURP OLPLWLQJ WKHLU FRPSODLQW WR DQ DPRXQW VWLOO
DGPLVVLEOHIRUDGMXGLFDWLRQE\WKH2PEXGVPDQZKLOHVDIHJXDUGLQJWKHLU
ULJKW WR UDLVH WKH UHPDLQLQJ SDUW RI WKH FODLP VXEVHTXHQWO\ LQ RUGHU WR
DUWL¿FLDOO\FUHDWHMXULVGLFWLRQRIWKH2PEXGVPDQ
b) Health, Long-Term Care and Credit Insurance Contracts (lit. b)
'LVSXWHVFRQFHUQLQJKHDOWKDQGORQJWHUPFDUHLQVXUDQFHFRQWUDFWVKDGWREH
H[FOXGHGIURPWKHMXULVGLFWLRQRIWKH2PEXGVPDQVLQFHWKHPRUHVSHFLDOLVHG
Association of [German] Private Healthcare Insurers (PKV) KDVHVWDEOLVKHG
LWVRZQRPEXGVPDQSURFHGXUHWKHPKV-Ombudsman$FRPSODLQWZKLFK
UHJDUGV WKH DIRUHPHQWLRQHG FRQWUDFW W\SHV LV QRW WUDQVPLWWHG E\ WKH
)RUDYHU\WKRURXJKDVVHVVPHQWRIWKHVHPDWWHUVVHHHÖVELLQ+DOP(QJHOEUHFKW.UDKH
HGVIQFKSDUDVHWVHTT
7KHVHDVSHFWVRIZKHQDoffengelegte TeilbeschwerdeLVJLYHQDUHH[WHQVLYHO\WUHDWHGE\
HÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD
RÖMERIQS
6HHVXSUDFK,,7KH¿UVW2PEXGVPDQODPHQWVVLQFHWKHH[LVWHQFHRIWZRRPEXGVPHQ
LVGXHWRFDXVHVRPHFRQIXVLRQZLWKSROLF\KROGHUVWKHIDFWWKDWKHDOWKLQVXUHUVFRXOGQRW
VHH ¿W WR EHFRPH PHPEHUV RI WKH Versicherungsombudsmann e.V. VHH RÖMER IQ S6XFKDFRQIXVLRQRIWKHSROLF\KROGHUVLVVWLOODUHDOLW\ZLWKRIDOOGLVPLVVDOV
EHLQJFDXVHGE\WKHIDFWWKDWWKHFRPSODLQWUHJDUGVDKHDOWKLQVXUHUFSOMBUDSMANN FÜR
VERSICHERUNGEN IQSIRUWKHUHDVRQVRIWKLVXQLODWHUDOLVWDSSURDFKRIWKHKHDOWK
insurers see LABES IQSSHWVHT
3URI'U-HQV*DO
2PEXGVPDQWRWKH3.92PEXGVPDQ,WLVKRZHYHUWKH2PEXGVPDQ¶V
SUDFWLFH WR LQIRUP D FRPSODLQDQW DERXW WKH H[LVWHQFH RI WKH DOWHUQDWLYH
GLVSXWHUHVROXWLRQSURFHGXUHDQGSURYLGHLWZLWKWKHDGGUHVV
6LQFHFUHGLWLQVXUDQFHLVXVXDOO\QRWWDNHQE\FRQVXPHUVRUFRQVXPHUOLNH
WUDGHVPHQWKHH[FOXVLRQRIFODLPVSHUWDLQLQJWRVXFKFRQWUDFWVKDVOLWWOH
SUDFWLFDOLPSRUWDQFHEXWLVDOPRVWH[FOXVLYHO\GHFODUDWRU\LQQDWXUH
c) Actuarial Methods or Formulae (lit. c)
$UH PRUHRYHU LQDGPLVVLEOH VXFK FRPSODLQWV ZKLFK WXUQ RQ WKH TXHVWLRQ
LIDQDFWXDULDOPHWKRGRUIRUPXODLVFRUUHFWRUODZIXO7KLVH[FOXVLRQZDV
SUHVXPDEO\ LQFOXGHG VLQFH WKH 2PEXGVPDQ ZRXOG RQ WKH RQH KDQG EH
RYHUEXUGHQHGWRGHFLGHVXFKFDVHVDQGRQWKHRWKHUKDQGDSSHDUWREHQRW
the right venueVLQFHVXFKDFRPSODLQWZRXOGEHRIRYHUDUFKLQJLQWHUHVW
QRWOLPLWHGWRWKHFRPSODLQDQWLQTXHVWLRQ:KLOVWWKHFRPSODLQWPD\QRW
WXUQRQWKHFRUUHFWQHVVRUODZIXOQHVVRIDFWXDULDOPHWKRGVDQGIRUPXODH
LW PD\ KRZHYHU UHJDUG WKH FRUUHFW DSSOLFDWLRQ RI WKHVH PHWKRGV DQG
IRUPXODHWRWKHFRPSODLQDQWLQTXHVWLRQ100
d) Third Party Claims (lit. d)
$UDWKHULPSRUWDQWH[FHSWLRQIURPMXULVGLFWLRQLVSURYLGHGE\VHFVXEVHF
OLWG5R3$FFRUGLQJWRWKLVSURYLVLRQWKH2PEXGVPDQPD\QRWKHDUDQ\
WKLUGSDUW\¶VFODLPUHJDUGLQJWKHLQVXUDQFHEHQH¿WV,QVRPHUHVSHFWVWKLV
H[FHSWLRQPLJKWEHUHJDUGHGDVRQO\GHFODUDWRU\VLQFHSXUVXDQWWRVHF
VXEVHFOLWD5R3WKH2PEXGVPDQLVRQO\FRPSHWHQWWRKHDUFRPSODLQWV
UHJDUGLQJownFRQWUDFWXDOFODLPVRXWRIDQLQVXUDQFHFRQWUDFW101,QVRIDUWKLUG
SDUW\FODLPVZRXOGQRWHQWHULQWRWKHMXULVGLFWLRQRIWKH2PEXGVPDQLQWKH
¿UVWSODFHDQGZRXOGWKXVQRWKDYHWREHH[FOXGHG1027KLVQRWZLWKVWDQGLQJ
LWVHHPVIDYRXUDEOHWRKDYHLQFOXGHGWKHH[FHSWLRQLIRQO\IRUWKHVDNHRI
FODULW\)XUWKHUPRUHWKHUHLVJRRGUHDVRQWREHOLHYHWKLVUXOHWRKDYHVRPH
FRQVWLWXWLYHHIIHFWDVZHOO,WVKRXOGKRZHYHUEHFOHDUWKDWWKLUGSDUW\
VKRXOGQRWEHXQGHUVWRRGWRPHDQDQ\ERG\EXWWKHSROLF\KROGHU$VZDV
GHPRQVWUDWHGDERYHFRLQVXUHGSHUVRQVDQGEHQH¿FLDULHVPD\QRWper se
$FFRUGLQJWRHÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUDRQWKHRQH
KDQGRQHFDQQRWDVVXPHWKHFRQVHQWRIWKHFRPSODLQDQWIRUVXFKDWUDQVPLVVLRQWRRFFXU
SCHERPE IQSRQWKHRWKHUKDQGDGYRFDWHVDQLQFOXVLRQRIDGXW\WRUHPLWLQWR
WKHSURFHGXUDOUXOHV
SCHERPE IQS
100
101
6HHVXSUDFK9
102
,QWKLVVHQVHSCHERPE IQSZKRWKLQNVWKLVH[FHSWLRQWREHVXSHUÀXRXV
)RUDOLVWRIVXFKSHUVRQVWKDWPLJKWEHHQFRPSDVVHGE\WKLVH[FOXVLRQVHHLABESIQ
S
EH H[FOXGHG IURP WKH RPEXGVPDQ SURFHGXUH104 DQG VKRXOG WKXV QRW EH
UHJDUGHGDVDWKLUGSDUW\LWLVDGLIIHUHQWTXHVWLRQDOWRJHWKHULIWKH\KDYH
an ownFODLPLQWKHFDVHLQTXHVWLRQ
e) Lis pendens (lit. e)
7KHFRPSODLQWLVIXUWKHUPRUHDWOHDVWWHPSRUDULO\LQDGPLVVLEOHLIDFDVH
ZLWKWKHVDPHVXEMHFWPDWWHULVSHQGLQJEHIRUHDFRXUWDUELWUDOWULEXQDO
GLVSXWH UHVROXWLRQ LQVWLWXWLRQ RU WKH LQVXUDQFH VXSHUYLVRU\ DXWKRULW\ ,Q
WKLVUHVSHFWWKHRPEXGVPDQSURFHGXUHLVQRWLQWHQGHGWRWDNHSUHFHGHQW
DVLWLVWROHDYHWKHFRPSODLQDQWWKHIXOODXWRQRP\DVWRZKHUHWRORGJH
KLVFODLP,IKRZHYHUWKHFRPSODLQDQWFKRRVHVWRORGJHWKHFODLPDWDQ\
RIWKHHQXPHUDWHGYHQXHVHYHQDIWHUWKHFRPSODLQWZDVUHJLVWHUHGDWWKH
RPEXGVPDQRI¿FHWKHFRPSODLQWEHFRPHVLQDGPLVVLEOH$VVRRQDVWKHFDVH
LVQRORQJHUSHQGLQJEHIRUHRQHRIWKHDIRUHPHQWLRQHGYHQXHV±DQGLIWKH
PDWWHUZDVQRWGHFLGHGRWKHUZLVHVHFVXEVHFOLWI5R3DSSOLHV±WKH
FRPSODLQWEHFRPHVDGPLVVLEOHDJDLQ,WVKRXOGEHKLJKOLJKWHGWKDWWKH
FRPSODLQWLVDOVRLQDGPLVVLEOHLIWKHLQVXUDQFHXQGHUWDNLQJKDVLQVWLJDWHG
FRXUW SURFHHGLQJV HJ LQ RUGHU WR FODLP WKH SD\PHQW RI WKH SUHPLXP
EHIRUHWKHFRPSODLQWDERXWWKHSROLF\KROGHU¶VSHUFHSWLRQWKDWVXFKDFODLP
LVLQH[LVWHQWZDVORGJHG7KHJURXQGVIRULQDGPLVVLELOLW\RIVHFVXEVHF
OLWH5R3GRKRZHYHUQRWDSSO\LIWKHLQVXUHUZHUHWRORGJHDFODLPDWD
ODWHUVWDJHDRQFHDGPLVVLEOHFRPSODLQWRIWKHFRQVXPHUZLOOQRWEHWXUQHG
LQWRDQLQDGPLVVLEOHRQH2WKHUZLVHWKHLQVXUHUFRXOGUDQGRPO\GHSULYHWKH
FRQVXPHU RI KLV ULJKW RI FRPSODLQW EHIRUH WKH 2PEXGVPDQ 7KH LQVXUHU
LVUDWKHUUHJDUGHGRIKDYLQJDJUHHGWRDpactum de non petendo106ZKLFK
ZRXOGPDNHLWVFRXUWFODLPLQDGPLVVLEOHIRUWKHWLPHEHLQJ
:KLOH PRVW YHQXHV LH VWDWH FRXUW DUELWUDO WULEXQDO DQG RWKHU GLVSXWH
UHVROXWLRQLQVWLWXWLRQDUHSUHWW\VHOIH[SODQDWRU\VRPHZRUGVQHHGWREH
VDLGDERXWWKHLQVXUDQFHVXSHUYLVRU\DXWKRULW\LHWKHBundesanstalt für
Finanzdienstleistungsaufsicht %D)LQ 3XUVXDQW WR VHF E RI WKH $FW RQ
WKH)LQDQFLDO6XSHUYLVRU\$XWKRULW\Finanzdienstleistungsaufsichtsgesetz
[FinDAG@ the customers RI ¿QDQFLDO LQVWLWXWLRQV VXFK DV inter alia
LQVXUDQFH XQGHUWDNLQJV PD\ DGGUHVV D FRPSODLQW WR WKH %D)LQ 7KLV
104
6HHVXSUDFK9DDQG
7KLVLVDSRVLWLYHGLIIHUHQFHWRRWKHURPEXGVPDQSURFHGXUHVLQZKLFKSHQGHQF\RIDFDVHZLOO
RIWHQUHVXOWLQSHUPDQHQWLQDGPLVVLELOLW\FSHJVHFVXEVHFOLWD9HUIDKUHQVRUGQXQJ
IUGLH6FKOLFKWXQJYRQ.XQGHQEHVFKZHUGHQLPGHXWVFKHQ%DQNJHZHUEH
106
&SHJV. HIPPELIQSSHWVHT
7KLVVHFWLRQZDVLQWURGXFHGLQE\WKH/DZRQWKH5HLQIRUFHPHQWRI)LQDQFLDO6XSHUYLVLRQ
Gesetz zur Stärkung der deutschen FinanzaufsichtLQ%*%O,SS+RZHYHU
WKHSRVVLELOLW\WRSHWLWLRQWKH%D)LQKDVH[LVWHGIRUDORQJWLPHFSUHFHQWO\%D)LQFLUFXODU
EHIRUH
7KHFRPSODLQWLVDOVRRSHQWRFHUWDLQFRQVXPHUSURWHFWLRQRUJDQLVDWLRQV
3URI'U-HQV*DO
FRPSODLQWLVKRZHYHUQRWWREHPLVWDNHQZLWKDFRPSODLQWLQWKHVHQVHRI
WKHRPEXGVPDQSURFHGXUHEXWLVPRUHDNLQWRDSHWLWLRQ7KHSURFHGXUH
EHIRUHWKH%D)LQLVUHVWULFWHGWRVXSHUYLVRU\DVSHFWVDQGLVQRWLQWHQGHG
WRDIIRUGWKHFRPSODLQDQWLQGLYLGXDOSURWHFWLRQ110:KLOHWKH2PEXGVPDQ
ZLOO QRW DGPLW D FRPSODLQW ZKLOH WKH PDWWHU LV SHQGLQJ EHIRUH WKH %D)LQ
±LQRUGHUWRDYRLGSDUDOOHOZRUNDQGWRDYRLGFRQWUDGLFWRU\GHFLVLRQV±
WKHFRPSODLQDQWPD\DGGUHVVWKHFRPSODLQWWRKLPDIWHUWKHSURFHHGLQJV
EHIRUH %D)LQ DUH FRQFOXGHG ,Q WKLV UHVSHFW WKH GHFLVLRQ RI %D)LQ VLQFH
LWGRHVQRWUHJDUGWKHLQGLYLGXDOSRVLWLRQRIWKHFRPSODLQDQWKDVQRres
iudicataHIIHFW
2QH¿QDOO\QHHGVWRSRLQWRXWWKDWWKHLQLWLDWLRQRIDQRUGHUIRUSD\PHQW
SURFHGXUH Mahnverfahren UHJDUGLQJ WKH SD\PHQW RI WKH SUHPLXP LV
QRW WR EH FRQVLGHUHG WR KDYH D lis pendensHIIHFW 7KLV SURFHGXUH LV D
SXUHO\ DXWRPDWHG SURFHGXUH LQ ZKLFK WKH FRXUW RUGHU LV LVVXHG ZLWKRXW
DQHYDOXDWLRQRIWKHXQGHUO\LQJFODLP7KHRUGHUKRZHYHURQO\EHFRPHV
ELQGLQJ LI WKH UHVSRQGHQW LQ WKLV FDVH WKH SROLF\KROGHU GRHV QRW REMHFW
WRWKHRUGHULQGXHWLPH111,QVRIDUWKLVSURFHGXUHLVQRWFRQWUDGLFWRU\LQ
WKHVWULFWVHQVHDQGLWZRXOGEHSUREOHPDWLFLIWKHLQVXUHUFRXOGUHQGHUD
FRPSODLQW E\ WKH SROLF\KROGHU LQDGPLVVLEOH E\ DSSO\LQJ IRU DQ RUGHU IRU
SD\PHQWWREHLVVXHG112
f) Res Iudicata (lit. f)
&HUWDLQ GHFLVLRQV DQG DJUHHPHQWV DUH DIIRUGHG D res iudicataHIIHFW DQG
PDNH D FRPSODLQW SHUPDQHQWO\ LQDGPLVVLEOH ZLWKLQ WKH RPEXGVPDQ
SURFHGXUH7KH2PEXGVPDQPD\QRWKHDUDFRPSODLQWLIWKHVDPHVXEMHFW
PDWWHUKDVDOUHDG\EHHQFRQFOXVLYHO\DGGUHVVHGE\WKHGHFLVLRQRIDVWDWH
FRXUWDUELWUDOWULEXQDORUGLVSXWHUHVROXWLRQLQVWLWXWLRQ7KHVDPHDSSOLHV
ZKHUHWKHSDUWLHVKDYHUHDFKHGDIRUPDORXWRIFRXUWVHWWOHPHQWDQGZKHUH
DQDSSOLFDWLRQIRUOHJDODLGProzesskostenhilfeLVGHQLHGRQWKHJURXQGVRI
LQVXI¿FLHQWSURVSHFWRIVXFFHVV
&SLAARS)LQDQ]GLHQVWOHLVWXQJVDXIVLFKWVJHVHW]QGHG0XQLFKVHFESDUD
110
LAARSIQVHFESDUD
111
7REHFOHDURQFHWKHRUGHUKDVEHFRPHELQGLQJGXHWRQRQREMHFWLRQLWKDVDres iudicata
HIIHFWDQGWKHFRPSODLQWEHFRPHVLQDGPLVVLEOHSXUVXDQWWRVHFVXEVHFOLWI5R3DQG
LI WKH SROLF\KROGHU REMHFWV DQG WKH PDWWHU LV WUDQVIHUUHG WR WKH FRPSHWHQW WULDO FRXUW
WKH FRPSODLQW EHFRPHV LQDGPLVVLEOH SXUVXDQW WR VHF VXEVHF OLW H 5R3 ,Q SUDFWLFH
WKH 2PEXGVPDQ ZLOO UHTXHVW WKH XQGHUWDNLQJ WR HIIHFW D VWD\ RI WKH RUGHU IRU SD\PHQW
SURFHHGLQJVDFFRUGLQJWRVHFVXEVHF5R3WKHXQGHUWDNLQJKDVDGXW\WRFRQIRUP
ZLWKWKLVUHTXHVW
112
&SRQWKHZKROHHÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD
6HHLQPRUHGHWDLOHÖVELLQ+DOP(QJHOEUHFKW.UDKHHGVIQFKSDUD
g) Criminal Proceedings (lit. g)
$FRPSODLQWLVHTXDOO\LQDGPLVVLEOHLIWKHFRPSODLQDQWKDVSUHVVHGFULPLQDO
FKDUJHVRUSUHVVHVFULPLQDOFKDUJHVDIWHUWKHFRPSODLQWKDVEHHQORGJHG
UHJDUGLQJWKHRFFXUUHQFHVWKDWDUHDOVRWKHVXEMHFWRIWKHFRPSODLQW7KRXJK
this is not a lis pendensPDWWHUVLQFHWKH2PEXGVPDQGHFLGHVRQO\FLYLO
ODZDVSHFWVRIDFRPSODLQWKHZLOOQHYHUWKHOHVVQRWDGPLWWKHFRPSODLQW
7KHUDWLRQDOHEHKLQGWKLVUXOHLVWKDWWKH2PEXGVPDQLVLQWHQGHGWRKDYH
D SDFLI\LQJ HIIHFW ZKLFK LV QR ORQJHU SRVVLEOH RQFH WKH ODZ HQIRUFHPHQW
DJHQFLHV DUH LQYROYHG114 2QH H[FHSWLRQ LV KRZHYHU PDGH ZKHUH WKH
FRPSODLQDQWKDVSUHVVHGRQO\VXFKFULPLQDOFKDUJHVDVKHZDVUHTXLUHGWR
GRLQRUGHUQRWWRHQGDQJHUKLVLQVXUDQFHFRYHU+HUHWKHFRPSODLQDQW¶V
ZLOOLQJQHVVWREHUHFRQFLOHGLVQRWFDOOHGLQWRTXHVWLRQE\KLVSUHVVLQJRI
FKDUJHVDQGWKHLQVXUHULVH[SHFWHGWRXQGHUVWDQGVXFKDFWLRQVZKLFKDUH
FDXVHGE\>LWVSURSHU@FRQWUDFWXDOFRQGLWLRQV
h) Manifestly Unfounded Claim (lit. h)
7KHUXOHVRISURFHGXUHPRUHRYHULQFOXGHDQH[FHSWLRQIURPMXULVGLFWLRQ
RIVXFKFODLPVZKLFKDUHPDQLIHVWO\ZLWKRXWDQ\SURVSHFWRIVXFFHVV7KLV
H[FOXVLRQFRXOGKDYHKDGDYHU\VHYHUHHIIHFWLIWKHRPEXGVPDQSURFHGXUH
ZRXOGSURYLGHIRUDQHQWU\VWDJHLQVWDQFHZLWKRXWWKH2PEXGVPDQ¶VFRQWURO
DVLVWKHFDVHLQVRPHRPEXGVPDQSURFHGXUHV6XFKDQLQVWDQFHFRXOG
RYHUHPSKDVLVLWVUROHDQGEHTXLFNLQDVVHVVLQJDFRPSODLQWWREHPDQLIHVWO\
XQIRXQGHG DQG LQ WKLV ZD\ FLUFXPYHQW WKH SDUWLFXODU RPEXGVPDQ¶V
DXWKRULW\ 7KLV SUREOHP LV LQH[LVWHQW IRU WKH Versicherungsombudsmann
7KRXJKLWLVWKHHPSOR\HHVRIWKHVRFDOOHGVHUYLFHFHQWUH116ZKRUHFHLYH
WKH FRPSODLQWV DQG DOVR PDNH D ¿UVW HYDOXDWLRQ RI ZKHWKHU RU QRW WKH
2PEXGVPDQLVFRPSHWHQWDQGPD\GLVPLVVDFODLPDVLQDGPLVVLEOHWKH\
IXO¿OWKHLUWDVNIXOO\VXERUGLQDWHGWRWKH2PEXGVPDQ)RUWKLVDQGRWKHU
UHDVRQV WKLV H[FHSWLRQ KDV QRW JDLQHG DQ\ SUDFWLFDO LPSRUWDQFH but
KDV EHHQ UHVHUYHG WR GHDO ZLWK WKH FRPSODLQWV RI LQYHWHUDWH TXHUXORXV
SHUVRQV,QPRVWRWKHUFDVHVLQVWHDGRIWHOOLQJFRPSODLQDQWVWKDWWKHLU
FRPSODLQW ZDV LQDGPLVVLEOH WKH 2PEXGVPDQ KDV UHJDUGHG LW DV JRRG
114
SCHERPE IQ S DSSDUHQWO\ PLVWDNHV WKH UDWLRQDOH EHKLQG WKLV H[FHSWLRQ ZKHQ
GHPDQGLQJWKDWWKHRPEXGVPDQSURFHGXUHVKRXOGEHFRPHDYDLODEOHDJDLQDIWHUFRQFOXVLRQ
RIWKHFULPLQDOSURFHHGLQJV
3RLQWHGRXWE\ V. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUD
IQ 7KLV ZDV QRWDEO\ WKH FDVH IRU WKH FRPSODLQW FHQWHU RI WKH *HUPDQ %DQNLQJ
2PEXGVPDQFSVHFRILWVSURFHGXUDOUXOHVXQWLO
116
6HHVXSUDFK,9DQGLQIUDFK9,DQG
7KHQXPEHURIFDVHVGLVPLVVHGRQWKHVHJURXQGVLVDSSDUHQWO\VRORZWKDWLWGRHVQRWHYHQ
¿JXUHLQGLYLGXDOO\LQWKH2PEXGVPDQ¶VVWDWLVWLFVRQLQDGPLVVLEOHFODLPVFSOMBUDSMANN FÜR
VERSICHERUNGEN IQS
&SDOUHDG\RÖMERIQS
3URI'U-HQV*DO
SROLF\ LQ RUGHU WR UHHVWDEOLVK JRRG UHODWLRQV EHWZHHQ WKH SROLF\KROGHU
DQGKLVLQVXUHUWRH[SODLQWRWKHFRPSODLQDQWVLQDUHDVRQHGGHFLVLRQZK\
WKHLUFODLPLVXQIRXQGHG
i) Prescribed Claim (lit. i)
$UH¿QDOO\LQDGPLVVLEOHVXFKFRPSODLQWVZKLFKUHJDUGDSUHVFULEHGFODLP
LI WKH UHVSRQGHQW UDLVHV WKH REMHFWLRQ RI SUHVFULSWLRQ 7KLV H[FHSWLRQ LV
V\VWHPDWLFDOO\LQFRQWUDGLFWLRQWR*HUPDQODZ120 since prescription is not
UHJDUGHGDVDSURFHGXUDOTXHVWLRQDVLQFRPPRQODZMXULVGLFWLRQVEXWDV
UHJDUGLQJWKHPHULWV,IDUHVSRQGHQWUDLVHVWKHREMHFWLRQRISUHVFULSWLRQ
WKHFDVHLVQRWWXUQHGLQDGPLVVLEOHEXWUDWKHUEHFRPHVXQIRXQGHGVLQFH
WKH FODLP LV QRW HQIRUFHDEOH ,Q FDVH RI WKH RPEXGVPDQ SURFHGXUH ±
ZKLFKGRHVQRWSURYLGHIRUDGHFLVLRQELQGLQJRQWKHFRPSODLQDQWDQGLV
IUHHRIFKDUJHIRUKLP±WKHGLIIHUHQFHVEHWZHHQWKHVHWZRDSSURDFKHVZLOO
KRZHYHUEHUDWKHUQHJOLJLEOH
5. Unsuitability
(YHQ LI D FRPSODLQW LV DGPLVVLEOH WKH 2PEXGVPDQ PD\ QHYHUWKHOHVV
GHFOLQH MXULVGLFWLRQ LI WKH FRPSODLQW DSSHDUV XQVXLWDEOH IRU DGMXGLFDWLRQ
ZLWKLQWKHRPEXGVPDQSURFHGXUH7KHJURXQGVRQZKLFKVXFKXQVXLWDELOLW\
PD\EHEDVHGDUHHQXPHUDWHGLQVHF5R3
,WLVWREHVWUHVVHGWKDWDOOJURXQGVIRUXQVXLWDELOLW\±H[FHSWIRUWKHRQH
XQGHUVXEVHF±E\DSSO\LQJWKHWHUP³PD\´kannJUDQWWKH2PEXGVPDQ
VRPHOHHZD\LQGHFLGLQJZKHWKHURUQRWWRGHFOLQHMXULVGLFWLRQ,WLVWREH
DVVXPHGWKDWWKH2PEXGVPDQZKHQLQGRXEWZLOOUDWKHUDVVXPHMXULVGLFWLRQ
WKDQGHFOLQHLW&RQFHUQLQJWKHSRVVLELOLW\WRGHFOLQHMXULVGLFWLRQ EHFDXVH
WKHUHOHYDQWTXHVWLRQVDUHFRQWURYHUVLDODQGKDYHQRWEHHQGHFLGHGE\WKH
KLJKHVWFRXUWVPDWWHUVDSSHDUGLIIHUHQWO\+HUHWKHUXOHVRISURFHGXUHDSSO\
WKH WHUP ³VKDOO´ soll LQGLFDWLQJ WKDW WKH 2PEXGVPDQ LV WR PDQGDWRULO\
GHFOLQHMXULVGLFWLRQ
a) Scope of Proceedings (Subsec. 1)
-XULVGLFWLRQ PD\ EH GHFOLQHG GXULQJ DQ\ VWDJH RI WKH SURFHHGLQJV LI LW
EHFRPHV DSSDUHQW WKDW WKH WDNLQJ RI WKH GRFXPHQWDU\ HYLGHQFH WKH
RQO\ HYLGHQFH DGPLWWHG LQ WKH SURFHGXUH ZLOO DWWDLQ VXFK D VFRSH DV WR
XQGXO\RYHUEXUGHQWKHFDSDFLWLHVRIWKH2PEXGVPDQDQGKLVVWDII6XFK
D FRPSODLQW ZRXOG EH XQVXLWDEOH WR WKH 2PEXGVPDQ SURFHGXUH ZKLFK LV
LQWHQGHGWREHDVZLIWDQGXQEXUHDXFUDWLFDVVLVWDQFHLQLQVXUDQFHUHODWHG
GLVSXWHV121,WLVGLI¿FXOWWRVHHKRZWKHVHJURXQGVIRUGLVPLVVDOZRXOGHYHU
RÖMERIQS
120
&SV. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUDRÖMERIQS
121
EHFRPHDSSOLFDEOHLQSUDFWLFHVLQFHWKHSURFHGXUHRQO\DOORZVIRUFODLPV
E\FRQVXPHUVRUFRQVXPHUOLNHWUDGHVPHQ122
b) Controversial Legal Questions (Subsec. 2)
0XFKPRUHLPSRUWDQWDUHWKHVXEVHTXHQWJURXQGVIRUGLVPLVVDO$FFRUGLQJ
WRVHFVXEVHF5R3WKH2PEXGVPDQVKDOOGHFOLQHMXULVGLFWLRQLIWKH
FRPSODLQWUDLVHVDOHJDOTXHVWLRQZKLFKLVGHFLVLRQUHOHYDQWFRQWURYHUVLDO
DQGKDVQRWEHHQGHFLGHGE\WKHKLJKHVWFRXUWV(YHQWKRXJKWKHVHJURXQGV
IRUGLVPLVVDOKDYHEHHQFULWLFLVHGE\VRPHWKH\FDQQRWEHGHVFULEHGDV
H[RUELWDQW 7KH H[FHSWLRQ LV LQWHQGHG WR UHVHUYH OHJDO TXHVWLRQV ZKRVH
LPSRUWDQFHJRIDUEH\RQGWKHLQGLYLGXDOFDVHWRWKHFRXUWV124&RQVLGHULQJ
WKHVLPSOL¿HGSURFHGXUHEHIRUHWKH2PEXGVPDQKLVSRVVLELOLW\WRSXEOLVK
GHFLVLRQVDQGWKH¿QDOLW\RIKLVGHFLVLRQVXSWRWKHDPRXQWRI¼
RQH PD\ XQGHUVWDQG WKH UHOXFWDQFH RI WKH LQVXUDQFH LQGXVWU\ WR KDYH
FRQWURYHUVLDOTXHVWLRQVVHWWOHGLQWKLVSURFHGXUHDQGDSRVVLEOH³SUHFHGHQW´
FUHDWHG,WVHHPVUDWKHUXQGHUVWDQGDEOHWKDWVXFKFDVHVVKRXOGEHOHIWWR
WKHFRXUWVDQGLQWKHHQGWKHBundesgerichtshofVKRXOGQRWEHGHSULYHGRI
¿QDOO\VHWWOLQJVXFKFRQWURYHUVLDOTXHVWLRQV
$FFRUGLQJWRWKHSUHVHQW2PEXGVPDQ¶VDFFRXQWKH³URXWLQHO\UHIUDLQVIURP
GHDOLQJ ZLWK FRPSODLQWV ZKLFK UDLVH TXHVWLRQV WKH LPSRUWDQFH RI ZKLFK
JRHVIDUEH\RQGWKHLQGLYLGXDOFDVHDVLVXVXDOO\WKHFDVHZLWKTXHVWLRQV
FRQFHUQLQJWKHHIIHFWLYHQHVVRULQHIIHFWLYHQHVVRIDFODXVHLQJHQHUDOSROLF\
FRQGLWLRQV´126 ,QVRIDU WKHUH DUH D QRWLQVLJQL¿FDQW QXPEHU RI FDVHV WKDW
WKH2PEXGVPDQPD\LIQRWVKDOOGLVPLVVRQWKHVHJURXQGV
c) Remote Fields of Law (Subsec. 3)
0RUHRYHUWKH2PEXGVPDQPD\GHFOLQHMXULVGLFWLRQLIWKHFRPSODLQWKLQJHV
RQGHFLVLRQUHOHYDQWOHJDOTXHVWLRQVZKLFKUHJDUGWKHDSSOLFDWLRQRIIRUHLJQ
ODZRUVSHFLDOOHJDOUHJLPHVHJWD[ODZ$JDLQWKHRPEXGVPDQSURFHGXUH
LV LQWHQGHG WR EH D VZLIW DQG XQEXUHDXFUDWLF DVVLVWDQFH LQ GLVSXWHV ZLWK
*HUPDQLQVXUHUV$VVXFKWKH2PEXGVPDQDQGKLVVWDIIDUHVSHFLDOLVHGLQ
VZLIWO\ DQGFRUUHFWO\DSSO\LQJ *HUPDQLQVXUDQFHODZ 'HDOLQJZLWK FDVHV
XQGHU WKH DSSOLFDWLRQ RI IRUHLJQ ODZ RU ZKHUH XQW\SLFDO ¿HOGV RI ODZ DUH
122
,QWKLVVHQVHDOUHDG\SCHERPE IQS
SCHERPE IQS
124
HIRSCH IQS
7KH VDPH UHVXOW RQH PLJKW DGG ZRXOG KDYH EHHQ UHDFKHG LI RQH KDG GLVDOORZHG WKH
2PEXGVPDQWRSXEOLVKGHFLVLRQVUHODWLQJWRVXFKTXHVWLRQVDQGSUHVFULEHGWKHPWREHRQO\
SDVVHGLQWKHIRUPRIDQRQELQGLQJUHFRPPHQGDWLRQ
126
HIRSCH IQS
2YHUDOOGLVPLVVDORQDQ\RIWKHJLYHQJURXQGVLVQRWFRPSOHWHO\LUUHOHYDQWLQSUDFWLFH
VLQFHDERXWRIWKHDGPLVVLEOHFRPSODLQWVDUHWHUPLQDWHGLQWKLVZD\FSOMBUDSMANN
FÜR VERSICHERUNGEN IQS
3URI'U-HQV*DO
UHOHYDQWZRXOGUHTXLUHRXWVLGHDVVLVWDQFHRUYHU\H[WHQVLYHRFFXSDWLRQIRU
ERWKRIZKLFKWKHSURFHGXUHLVQRWHTXLSSHG
d) Model Case (Subsec. 4)
9HU\XQXVXDOJURXQGVIRUGLVPLVVDODUHSURYLGHGIRUE\VHFVXEVHF5R3
3XUVXDQWWRWKLVSURYLVLRQWKHUHVSRQGHQWLHWKHLQVXUDQFHXQGHUWDNLQJ
PD\UHTXHVWWKDWDFRPSODLQWEHGLVPLVVHGZLWKRXWGHFLVLRQRQWKHJURXQGV
WKDW LW LV D PRGHO FDVH 7KH 2PEXGVPDQ LV WR JUDQW WKLV UHTXHVW DV
ORQJ DV WKH XQGHUWDNLQJ PDNHV SODXVLEOH WKDW WKH FRPSODLQW WRXFKHV RQ
DOHJDOTXHVWLRQRIIXQGDPHQWDOVLJQL¿FDQFH7KH2PEXGVPDQKRZHYHU
RQO\JUDQWVWKHUHTXHVWLIWKHXQGHUWDNLQJWDNHVRQWKHREOLJDWLRQWRUHIXQG
WKHFRXUWDQGODZ\HUIHHVERUQHE\WKHFRPSODLQDQWLQUHODWLRQWRWKH¿UVW
LQVWDQFHRIFRXUWSURFHHGLQJV,WLVWREHQRWHGWKDW*HUPDQFLYLOSURFHGXUH
ODZLVEDVHGRQWKHUXOHWKDWWKHSDUW\ZKLFKGLGQRWSUHYDLOKDVWREHDU
DOOFRVWVRIWKHOHJDOGLVSXWHLHDOVRWKHFRVWVRIRSSRVLQJSDUW\WKRXJK
WKHUH DUH VRPH OLPLWV WR WKH H[WHQW WR ZKLFK LW GLG QRW SUHYDLO VHF &RGHRI&LYLO3URFHGXUH7KHVLJQL¿FDQFHRIWKHREOLJDWLRQRIWKHLQVXUHULV
LQVRIDUWKDWLWKDVWRUHIXQGDQ\FRVWVERUQHE\WKHFRPSODLQDQWHYHQLIWKH
ODWWHUGLGQRWSUHYDLOZLWKKLVODZVXLW
e) Other Dispute Resolution Mechanism Available (Subsec. 5)
/DVWO\PD\EHGLVPLVVHGFRPSODLQWVIRUZKLFKWKHXQGHUO\LQJLQVXUDQFH
FRQWUDFWSURYLGHVDQDSSURSULDWHGLVSXWHUHVROXWLRQPHFKDQLVPZKLFKKDV
QRW \HW EHHQ PDGH XVH RI 7KH 2PEXGVPDQ ZLOO IRU H[DPSOH GLVPLVV D
FRPSODLQWFRQFHUQLQJDQLQVXUDQFHRISURSHUW\IRUZKLFKWKHJHQHUDOWHUPV
DQG FRQGLWLRQV RI LQVXUDQFH SURYLGH IRU DQ H[SHUW SURFHGXUH :KHUH WKH
GLVSXWHUHJDUGVWKHDPRXQWRIWKHEHQH¿WVGXHRUWKHH[LVWHQFHRIDVSHFL¿F
FDXVHRIGDPDJHVXFKDQH[SHUWSURFHGXUHVHHPVPRUHDSWLQGHDOLQJZLWK
WKHGLVSXWHWKDQWKHRPEXGVPDQSURFHGXUHZKLFKLVPRVWO\LQWHQGHGIRU
WKHUHVROXWLRQRIGLVSXWHVRYHUOHJDODQGQRWIDFWXDOTXHVWLRQV
VI. Procedure
7KHSURFHGXUHEHIRUHWKH2PEXGVPDQPD\EHURXJKO\GLYLGHGLQWRWKUHH
VWDJHVWKHHQWU\VWDJHWKHUHPHGLDOVWDJHDQGWKHSURFHGXUDOGHFLVLRQ
VWDJH
,WKDVEHHQLPSOLHGWKDWWKHVHJURXQGVIRUGLVPLVVDOZHUHPRGHOHGDIWHUWKH(QJOLVKSUH
)26LQVXUDQFHRPEXGVPDQSURFHGXUHFSV. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQ
HGV IQ SDUD IQ ,Q DQ\ FDVH LW LV QRW HDV\ WR DVVHVV ZKLFK FDVHV ±
ZKLFK DUH QRW WR EH GLVPLVVHG XQGHU VXEVHF TXHVWLRQV ZKLFK DUH GHFLVLRQUHOHYDQW
FRQWURYHUVLDODQGKDYHQRWEHHQGHFLGHGE\WKHKLJKHVWFRXUWV±PLJKWEHQH¿WIURPWKHVH
JURXQGVIRUGLVPLVVDO
6HH LQ PRUH GHWDLO DQG ZLWK RWKHU H[DPSOHV HÖVEL LQ +DOP(QJHOEUHFKW.UDKH HGV
IQFKSDUD
1. Entry Stage
7KHSURFHGXUHEHIRUHWKH2PEXGVPDQLVLQFHSWHGZLWKWKHUHFHLSWRIWKH
FRPSODLQWE\WKH2PEXGVPDQVHFVXEVHFSKUDVH5R3ZKRLVWR
FRQ¿UPUHFHLSWDQGLQIRUPWKHFRPSODLQDQWDERXWWKHHQVXLQJSURFHGXUDO
SURFHVV VHF VXEVHF 5R3 7R DYRLG DQ\ XQFODULW\ LW VKRXOG EH
PHQWLRQHG WKDW WKH 2PEXGVPDQ ZLOO EH UHSUHVHQWHG DW WKLV VWDJH E\
WKH VHUYLFH FHQWUH VWDIIHG ZLWK SHRSOH WUDLQHG LQ WKH LQVXUDQFH EXVLQHVV
Versicherungskaufmann ,Q RUGHU WR DOORZ DQ HDV\ H[FHVV WR WKH
SURFHGXUHDQGWRPDNHFHUWDLQWKDWFRPSODLQWVPXVWQRWEHGLVPLVVHGIRU
SXUHO\IRUPDOUHDVRQVWKHFRPSODLQWPD\EHWUDQVPLWWHGE\DOOSUHYDOHQW
PHDQV RI FRPPXQLFDWLRQ LH YLD SKRQH OHWWHU ID[ RU HPDLO VHF VXEVHFSKUDVH5R3,QKLVFRPSODLQWWKHFRPSODLQDQWLVH[SHFWHGWR
IRUPXODWHDFOHDUDQGXQDPELJXRXVFODLPWRFRQYH\DOOHVVHQWLDOIDFWVDQG
WUDQVPLWDOOQHFHVVDU\GRFXPHQWVVHFVXEVHFSKUDVH5R3:KHUH
WKHFRPSODLQWLVODFNLQJLQWKLVUHVSHFWWKHVHUYLFHFHQWUHVWDIIUHSUHVHQWLQJ
WKH2PEXGVPDQZLOOFRQWDFWWKHFRPSODLQDQWWRDLGKLPLQIRUPXODWLQJWKH
FODLPPDNLQJFOHDUWKHIDFWXDOFLUFXPVWDQFHVDQGLGHQWLI\LQJWKHQHFHVVDU\
GRFXPHQWVVHFVXEVHFSKUDVH5R37KHVWDIIPHPEHUVPD\HYHQ
FRQWDFWWKHLQVXUDQFHXQGHUWDNLQJWRFODULI\WKHIDFWVRIWKHFDVHVHF
VXEVHFSKUDVH5R3,IDOOWKHVHDIIRUGVDUHLQVXI¿FLHQWLQEULQJLQJD
FOHDUDQGXQHTXLYRFDOWH[WIRUDFRPSODLQWWRIUXLWLRQWKHFRPSODLQDQWLV
LQIRUPHGWKDWXQGHUWKHVHFRQGLWLRQVSURFHHGLQJVPD\QRWEHFDUULHGRXW
DQGWKHSURFHGXUHLVWHUPLQDWHGVHFVXEVHF5R3
:LWKWKHUHFHLSWRIWKHFRPSODLQWWKH2PEXGVPDQ±UHSUHVHQWHGE\WKH
service centre±PDNHVWKH¿UVWHYDOXDWLRQLIWKHFODLPLVDGPLVVLEOH,I
WKHDQVZHULVLQWKHQHJDWLYHWKHFRPSODLQWLVGLVPLVVHG7KLVHYDOXDWLRQRI
WKH2PEXGVPDQ¶VMXULVGLFWLRQLVKRZHYHUWRWDNHSODFHGXULQJDOOVWDJHV
RIWKHSURFHHGLQJVVHFVXEVHF5R3,IWKH2PEXGVPDQZLVKHVWR
GLVPLVV D FODLP RQ WKHVH JURXQGV KH LV LQ SULQFLSOH KHOG WR JLYH WKH
SDUWLHV WKH RSSRUWXQLW\ WR PDNH D VWDWHPHQW DQG WR LVVXH D UHDVRQHG
GHFLVLRQVHFVXEVHF5R3
7KLV PRPHQW LV DOVR LPSRUWDQW VLQFH WKH SHULRG RI OLPLWDWLRQ RI WKH XQGHUO\LQJ FODLP LV
VXVSHQGHGIURPWKHPRPHQWDWZKLFKWKHFRPSODLQWLVUHFHLYHGFSVHFVXEVHF5R3
6HHVXSUDFK,9
7KHVHUYLFHFHQWHULVQRWLQGHSHQGHQWLQGHFLGLQJLIWKHFRPSODLQWLVLQDGPLVVLEOH±DVZDV
IRUH[DPSOHWKHFRPSODLQWFHQWHUIRUWKH*HUPDQ%DQNLQJ2PEXGVPDQ1U3URFHGXUDO
5XOHVXQWLO±EXWLVKDQGOLQJWKLVWDVNXQGHUWKHIXOODXWKRULW\RIWKH2PEXGVPDQ
6OLJKWO\PRUHWKDQDWKLUGRIDOOFRPSODLQWVDUHGLVPLVVHGRQWKHJURXQGVRIQRWIDOOLQJZLWKLQWKH
2PEXGVPDQ¶VMXULVGLFWLRQFSOMBUDSMANN FÜR VERSICHERUNGEN IQS7KLVDSSHDUVPRUH
SUREOHPDWLFWKDQLWDFWXDOO\LV2XWRIWKHVHFDVHVGLVPLVVHGRYHUUHJDUGHGGLVPLVVDOGXH
WRWKHIDFWWKDWWKHLQVXUHUZDVQRWDPHPEHUXQGHUWDNLQJWKDWWKHFRPSODLQWUHJDUGHGSULYDWH
KHDOWK LQVXUDQFH DQG WKDW QR SUHYLRXV FRPSODLQW KDG EHHQ DGGUHVVHG WR WKH LQVXUHU RU WKH
LQVXUHUZDVQRWJLYHQDPSOHWLPH>ZHHNV@WRGHDOZLWKWKHFRPSODLQWFSibidemS
3URI'U-HQV*DO
2. Remedial Stage
:LWKDGPLVVLELOLW\HVWDEOLVKHGWKHHPSOR\HHRIWKHVHUYLFHFHQWUHIRUZDUGV
WKHFRPSODLQWWRWKHPHPEHUXQGHUWDNLQJLQTXHVWLRQ,QGRLQJVRWKH
HPSOR\HHDFWLQJLQWKHQDPHRIWKH2PEXGVPDQUHTXHVWWKHXQGHUWDNLQJ
WR UHVSRQG WR WKH DOOHJDWLRQV DQG VHWV D WLPH OLPLW ZLWK WKH WLPH IRU
UHVSRQVHEHLQJRQHPRQWKFSVHFVXEVHFSKUDVH5R3,IWKH
LQVXUHUGRHVQRWUHVSRQGZLWKLQWKHHVWDEOLVKHGWLPHOLPLWWKH2PEXGVPDQ¶V
GHFLVLRQ ZLOO EH EDVHG VROHO\ RQ WKH FRPSODLQDQW¶V DVVHUWLRQV VHF VXEVHFSKUDVH5R3
,QWKLVUHJDUGWKHRQHPRQWKWLPHOLPLWLVRQHWKHRQHKDQGLQWHQGHGWR
DFFHOHUDWH WKH SURFHGXUH E\ LQFHQWLYLVLQJ VZLIW UHVSRQVHV RI WKH LQVXUHU
2QWKHRWKHUKDQGRQHPRQWKLVVWLOOUHJDUGHGWREHVXI¿FLHQWWLPHIRUWKH
LQVXUHUWRUHWKLQNLWVGHFLVLRQLQUHODWLRQWRWKHFRPSODLQW,WLVKLJKO\GHVLUHG
WKDWWKHLQVXUHUXQGHUWKH³WKUHDW´RIRPEXGVPDQSURFHHGLQJVUHHYDOXDWH
LWVSRVLWLRQDQGLILWVHHPV¿WUHPHG\WKHFODLPRIWKHFRPSODLQDQW,Q
VXFKDFDVHWKHUHLVQRIXUWKHUQHHGIRUWKHSURFHHGLQJVWRPRYHIRUZDUG
DQGWKHSURFHGXUHLVWHUPLQDWHG,IKRZHYHUWKHXQGHUWDNLQJGHFLGHVWR
UHPHG\WKHFODLPRQO\LQSDUWWKHTXHVWLRQDULVHVLIWKHSURFHGXUHFDQEH
WHUPLQDWHG+HUHLWGHSHQGVRQWKHFRPSODLQDQW¶VZLOOLQJQHVVWRDFFHSWWKH
GHFLVLRQDQGZLWKGUDZKLVFRPSODLQW1402WKHUZLVHWKHFRPSODLQWZRXOGEH
DOWHUHGWRRQO\FRYHUWKDWSDUWRIWKHFODLPWKDWLVVWLOOLQGLVSXWH$ERXW
RI DOO DGPLVVLEOH FRPSODLQWV DUH WHUPLQDWHG E\ WKH LQVXUHU¶V IUHH
GHFLVLRQWRUHPHG\WKHFODLP141
,IWKHLQVXUHUFKRRVHVQRWWRUHPHG\WKHFODLPEXWFRQWHVWLWLWZLOOVHQGLWV
7KHFRPSODLQWLVWUDQVPLWWHGWRWKHFRQWDFWSRLQWRIWKHXQGHUWDNLQJ$OOXQGHUWDNLQJVDUH
XQGHUDGXW\WRHVWDEOLVKVXFKDFRQWDFWSRLQWDQGLQIRUPWKH2PEXGVPDQDERXWLWFI
VHFVXEVHF5R3
7KH2PEXGVPDQPD\RQO\IRUJRUHTXHVWLQJDUHVSRQVHE\WKHLQVXUHULIWZRFXPXODWLYH
FULWHULD DUH PHW )LUVWO\ WKH FRPSODLQW PD\ EH VXI¿FLHQWO\ HYDOXDWHG YLD WKH PDWHULDOV
VXSSOLHG E\ WKH FRPSODLQDQW DQG VHFRQGO\ WKLV HYDOXDWLRQ OHDGV WR WKH UHVXOW WKDW WKH
FRPSODLQWLVPDQLIHVWO\XQIRXQGHGFSVHFVXEVHF5R3
7KHWLPHOLPLWPD\EHH[WHQGHGIRUXSWRDQDGGLWLRQDOPRQWKZKHUHVXFKVHHPVEHQH¿FLDO
VHF VXEVHF SKUDVH 5R3 :KLOVW PRVW DXWKRUV VHHP WR WKLQN WKDW WKLV ZLOO RQO\
RFFXUZKHQUHTXHVWHGE\WKHXQGHUWDNLQJFSHÖVELLQ+DOP(QJHOEUHFKW.UDKH>HGV@
>IQ@FKSDUDWKHZRUGLQJGRHVQRWGLVDOORZIRUWKH2PEXGVPDQWRH[WHQGWKH
time limit H[RI¿FLR
,IWKHLQVXUHU¶VUHVSRQVHLVEHODWHGWKH2PEXGVPDQPD\DGPLWVXFKUHVSRQVHLILWUHJDUGV
WKHGHOD\WREHH[FXVHGXQGHUWKHFLUFXPVWDQFHVVHFVXEVHFSKUDVHVDQG5R3
V. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUDRÖMERIQ
S
140
RÖMERIQS
141
OMBUDSMANN FÜR VERSICHERUNGEN IQS,QDQDGGLWLRQDORIWKHFDVHVWKHSDUWLHV
FRQFOXGHDVHWWOHPHQWDJUHHPHQWFSibidem
UHVSRQVHWRWKHFRPSODLQW7KLVUHVSRQVHZLOOLQWXUQXVXDOO\EHWUDQVPLWWHG
WRWKHFRPSODLQDQWVHFVXEVHF5R3
3. Procedural Stage
:LWKWKHUHPHGLDOVWDJHFRQFOXGHGWKHVHUYLFHFHQWUHWXUQVWKHFRPSODLQW
RYHUWRWKHOHJDOFHQWUHZLWKLWVIXOO\WUDLQHGODZ\HUVVolljuristen142 The
HPSOR\HH HQWUXVWHG ZLWK WKH FRPSODLQW FRUUHVSRQGV ZLWK DQ HPSKDVLV
RQ OHJDO PDWWHUV ZLWK DOO SDUWLHV LQ DQ DWWHPSW WR PDNH WKH FDVH UHDG\
IRUGHFLVLRQ7KH\DUHHTXDOO\H[SHFWHGWRVRXQGRXWWKHSRVVLELOLW\RIDQ
DPLFDEOHDUUDQJHPHQWDQGDLGWKHSDUWLHVLQFRPLQJWRVXFKDFRQFOXVLRQ
,IKRZHYHUQRVXFKDUUDQJHPHQWFDQEHEURNHUHGWKHHPSOR\HHZLOOWDNH
WKHGHFLVLRQVRQEHKDOIRIWKH2PEXGVPDQ,QGRLQJVRWKHHPSOR\HH
RI WKH OHJDO FHQWUH LV DFWLQJ XQGHU WKH DXWKRULW\ DQG VXSHUYLVLRQ RI WKH
2PEXGVPDQ,QPDNLQJFHUWDLQWKDWKLVYLHZVDUHIROORZHGWKH2PEXGVPDQ
KDVHVWDEOLVKHGJXLGHOLQHVIRUWKHHPSOR\HHVRIWKHOHJDOFHQWUHJUDQWHG
XQGHUZULWLQJDXWKRULW\WRFHUWDLQSHUVRQVIRUFHUWDLQFDVHVDQGHVWDEOLVKHG
ZKLFKTXHVWLRQVKDYHWREHWUDQVPLWWHGWRKLVSHUVRQDOUHYLHZ144$FFRUGLQJ
WRWKHVHDUUDQJHPHQWVDWOHDVWFDVHVRIJUHDWHULPSRUWDQFHRUZLWKPRUH
SUREOHPDWLFEHDULQJDUHXVXDOO\GHFLGHGE\WKH2PEXGVPDQLQSHUVRQ
,QFRPLQJWRDGHFLVLRQWKH2PEXGVPDQUHSUHVHQWHGE\WKHOHJDOFHQWUH
LVWRHVWDEOLVKWKHIDFWVH[RI¿FLRVHFVXEVHF5R37KLVPHDQVWKDW
WKH2PEXGVPDQWDNHVDQDFWLYHDSSURDFKDQGLVQRWLQWKHSDVVLYHUROH
RIDQ(QJOLVKFRXUWMXGJH7KLVDFWLYHUROHHYHQVXSHUVHGHVWKHDPRXQW
RI DFWLYLW\ GHPDQGHG RI DQG DOORZHG WR D *HUPDQ FRXUW MXGJH since the
SULQFLSOHRISURGXFWLRQRIHYLGHQFHBeibringungsgrundsatzLVQRWIXOO\
DSSOLFDEOH 7KH 2PEXGVPDQ PD\ UHTXHVW WKH SDUWLHV WR SURGXFH FHUWDLQ
GRFXPHQWVDQGPD\FRPPHQFHRZQLQYHVWLJDWLRQV146
7KHUHLVKRZHYHUDFHUWDLQUHVWULFWLRQ(YHQWKRXJKWKH2PEXGVPDQLV
IUHH LQ KLV FRQVLGHUDWLRQ RI HYLGHQFH VHF VXEVHF SKUDVH 5R3
LW LV QRW HQWUXVWHG ZLWK WKH WDNLQJ RI HYLGHQFH EHVLGHV GRFXPHQWDU\
HYLGHQFH VHF VXEVHF SKUDVH 5R3 2WKHU WKDQ XQGHU VRPH ROG
(QJOLVK RPEXGVPDQ VFKHPHV DQG WKH QHZ )26 WKHUH LV IRUPDOO\ QR
142
6HHVXSUDFK,9
7KLVLVUHJDUGHGWREHOHJDOXQGHUWKHDUWLFOHVRIDVVRFLDWLRQDQGWKHUXOHVRISURFHGXUH
see LORENZIQSLQSUDFWLFHWKHGHFLVLRQKDVWREHVLJQHGE\WZRHPSOR\HHVFR
MRLQWO\VHHibidemS
144
OMBUDSMANN
&SOMBUDSMANN FÜR VERSICHERUNGEN IQS)RUDGHVFULSWLRQRIKRZWKLVZDVGRQHDWOHDVW
GXULQJWKHIRUPDWLYH\HDUVFSRÖMERLQVERSICHERUNGSOMBUDSMANN E.V.HGIQS
FÜR
VERSICHERUNGEN IQS
146
&SV. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUD
&SV. HIPPELIQSSHWVHT
3URI'U-HQV*DO
SRVVLELOLW\IRUVLWHLQVSHFWLRQVH[SHUWRSLQLRQVDQGRUDOKHDULQJVWKRXJK
QRW HYHQ WKH (QJOLVK VFKHPHV DOORZHG IRU ZLWQHVV WHVWLPRQ\ ± EXW RQO\
DOORZHG IRU WKH SRVVLELOLW\ WR VRXQG RXW WKH FRPSODLQDQW¶V FUHGLELOLW\
DQG WKH SODXVLELOLW\ RI KLV FRPSODLQW 7KH 2PEXGVPDQ KDV KRZHYHU
DGDSWHG D YHU\ EURDG XQGHUVWDQGLQJ RI GRFXPHQWDU\ HYLGHQFH +H ZLOO
IRUH[DPSOHJLYHFRQVLGHUDWLRQWRZULWWHQZLWQHVVRUSDUW\VWDWHPHQWV
,W ZDV HYHQ KHOG SRVVLEOH WKDW ZKHUH ERWK SDUWLHV LQWURGXFH FRQÀLFWLQJ
ZULWWHQH[SHUWRSLQLRQVRURQHSDUW\LQWURGXFHVDQH[SHUWRSLQLRQZKLFKLV
FRQWUDGLFWRU\±VXFKZULWWHQH[SHUWRSLQLRQVZRXOGDOVREHIUHHO\DVVHVVHG
DV GRFXPHQWDU\ HYLGHQFH E\ WKH 2PEXGVPDQ ± WKH 2PEXGVPDQ PLJKW
EHDOORZHGWRPDQGDWHDQLQGHSHQGHQWH[SHUWRSLQLRQ)URPDOORIWKH
DERYHRQHPD\WDNHWKDWWKH2PEXGVPDQZLOODOZD\VGRKLVEHVWWRPDNH
DFRPSODLQWUHDG\IRUDGMXGLFDWLRQ7KHUHLVKRZHYHUDOLPLW,QWKHHQG
WKHSURFHGXUHLV±DVLVFODLPHGE\FXUUHQW2PEXGVPDQ*QWHU+LUVFK±D
ZULWWHQSURFHGXUH,QVRIDUDQ\FODLPWKDWVLPSO\FDQQRWEHGHFLGHGE\
WKHPHUHSURYLVLRQRIGRFXPHQWDU\PHDQVLVXQ¿WWLQJIRUWKH2PEXGVPDQ
DQGVKRXOGEHOHIWIRUWKHFRXUWV
VII. Decision
2QFH WKH 2PEXGVPDQ KDV HVWDEOLVKHG WKH IDFWV DQG LI WKH SURFHGXUH
ZDV QRW WHUPLQDWHG E\ WKH LQVXUHU KDYLQJ UHPHGLHG WKH FODLP E\ WKH
FRQFOXVLRQRIDVHWWOHPHQWDJUHHPHQWRUE\WKHFRPSODLQWEHLQJZLWKGUDZQ
E\ WKH FRPSODLQDQW WKH 2PEXGVPDQ HLWKHU LQ SHUVRQ RU UHSUHVHQWHG
E\ DQ HPSOR\HH RI WKH OHJDO FHQWUH WDNHV KLV GHFLVLRQ ,Q OLJKW RI WKH
HQRUPRXVFDVHORDGLWPD\RQO\EHFRQVLGHUHGDVWHOODUSHUIRUPDQFHWKDW
WKH2PEXGVPDQLVDEOHWRWHUPLQDWHDGPLVVLEOHFODLPVRQDYHUDJHLQOHVV
WKDQIRXUPRQWKV
:KLOH WKH 2PEXGVPDQ LV YHU\ IUHH LQ KLV DSSUHFLDWLRQ RI WKH HYLGHQFH
LWGRHVQRWHQMR\WKHVDPHIUHHGRPLQKLV¿QGLQJRIWKHGHFLVLRQ2WKHU
WKDQLQVRPH(QJOLVKRPEXGVPDQVFKHPHVRIWKHSDVWDQGSUHVHQW the
2PEXGVPDQ LV QRW HPSRZHUHG WR EDVH LWV GHFLVLRQV RQ ZKDW LV IDLU DQG
HTXLWDEOHLH DGHFLVLRQ ex aequo et bonoVHF5R3,WLVWKXVQHYHU
DSSURSULDWHIRUWKH2PEXGVPDQWRSDVVDGHFLVLRQDVDJRRGZLOOJHVWXUH
V. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUDRÖMERIQ
S
RÖMERIQSLQWKLVGLUHFWLRQDOVRSCHERPE IQS
HIRSCH IQS
OMBUDSMANN FÜR VERSICHERUNGEN IQS,QDGPLVVLEOHFODLPVDUHGHDOWZLWKLQDPDWWHU
RIGD\VUDWKHUWKDQZHHNVFSibidem
See V. HIPPELIQS)RUWKH)LQDQFLDO2PEXGVPDQ6HUYLFHVHHVHFRILWV7HUPV
RI5HIHUHQFH
40
VRFDOOHG Kullanzentscheidung ± KH PD\ DW EHVW LQIRUPDOO\ WHOO WKH
LQVXUHUWKLVZRXOGQRWEHDIRUPDOUHFRPPHQGDWLRQWKDWVXFKDJUDQWLQJ
RI WKH FODLP E\ WKH LQVXUHU DV D JRRGZLOO JHVWXUH PLJKW EH FDOOHG IRU
+HPXVWRQWKHFRQWUDU\EDVHKLVGHFLVLRQVROHO\RQWKHDSSOLFDEOHODZ
,QVXUDQFH FDSLWDO LQYHVWPHQW DQG VDOHV DQG GLVWULEXWLRQ SUDFWLFHV VR
FDOOHGWettbewerbsrichtlinienWKDWPD\LQÀXHQFHWKHLQVXUDQFHEXVLQHVV
VKDOOKRZHYHUEHJLYHQDPSOHUHJDUG7KHDIRUHVDLGVKRXOGKRZHYHUQRW
OHDGDQ\RQHWREHOLHYHWKDWFRQVLGHUDWLRQVRIIDLUQHVVDUHLUUHOHYDQWIRUWKH
2PEXGVPDQ7KH2PEXGVPDQZLOORQWKHFRQWUDU\JLYHGXHFRQVLGHUDWLRQ
WRDVSHFWVRIIDLUQHVVDQGHTXLW\ZKLFKKHLVDOORZHGWRGRXQGHUPDQ\RI
WKHYHU\EURDGEODQNHWFODXVHVGeneralklauselnRI*HUPDQODZHJ
*HUPDQ&LYLO&RGH*HUPDQ&LYLO&RGH>FRQFHUQLQJWKHLQWHUSUHWDWLRQ
RIJHQHUDOWHUPVDQGFRQGLWLRQV@
7KHGHFLVLRQVRIWKH2PEXGVPDQPD\WDNHRQWZRIRUPVGHSHQGLQJRQ
WKHDPRXQWLQGLVSXWH
1. Binding Decision
,IWKHDPRXQWLQGLVSXWHGRHVQRWH[FHHG¼WKH2PEXGVPDQ
WDNHVDELQGLQJGHFLVLRQVHFVXEVHFSKUDVHDOWHUQDWLYH5R3,WLV
WREHQRWHGWKDWDERXWRIDOOFRPSODLQWVUHJDUGDQDPRXQWLQGLVSXWH
WKDW LV EHORZ WKLV WKUHVKROG 7KH GHFLVLRQ LV WR EH SDVVHG LQ ZULWLQJ
must contain reasonsDQGZLOOEHWUDQVPLWWHGWRDOOSDUWLHVLPPHGLDWHO\
VHFVXEVHFSKUDVHVDQG5R37KHZD\WKHGHFLVLRQLVZULWWHQ
LQSUDFWLFHGHSHQGVWRDFHUWDLQGHJUHHRQLILWVDWLV¿HVWKHFRPSODLQDQW¶V
FODLP LQ IXOO DQG LV WKXV PRVWO\ DGGUHVVHG WR WKH XQGHUWDNLQJ RU LI WKH
FRPSODLQDQWKDVQRWEHHQDZDUGHGDWOHDVWSDUWRIKLVFODLP,QWKHODWWHU
FDVH WKH 2PEXGVPDQ ZLOO WU\ WR H[SODLQ LQ DFFHVVLEOH ODQJXDJH WR WKH
OD\PDQZK\KHFRXOGQRWSUHYDLO,QWKHIRUPHUFDVHWKH2PEXGVPDQZLOO
7KH¿UVW2PEXGVPDQRÖMERKDVLQGLFDWHGWKDWKHGLGDFWLQVXFKDZD\ZKHUHDSSURSULDWH
FLWHG LQ NITSCHKE 'LVNXVVLRQVEHULFKW LQ %DVHGRZ et al. HGV /HEHQVYHUVLFKHUXQJ ±
$OWHUVYRUVRUJH ± 3ULYDWH .UDQNHQYHUVLFKHUXQJ ± 9HUVLFKHUXQJ DOV *HVFKlIWVEHVRUJXQJ
± *HQWHVW ± 'HU 2PEXGVPDQQ LP 3ULYDWYHUVLFKHUXQJVUHFKW ± %HLWUlJH ]XU :LVVHQVFKDIWVWDJXQJGHV%XQGHVGHU9HUVLFKHUWHQ%DGHQ%DGHQS
See V. HIPPELIQS
)RUWKHFDOFXODWLRQRIWKHDPRXQWLQGLVSXWHVHHVXSUDFK9D
8SXQWLOWKH2PEXGVPDQFRXOGWDNHELQGLQJGHFLVLRQVRQO\LQFDVHVZLWKDQDPRXQW
LQGLVSXWHXSWR¼FSVERSICHERUNGSOMBUDSMANN E.V.HGIQS
OMBUDSMANN
FÜR
VERSICHERUNGEN IQS
7KRXJKQRWH[SOLFLWO\GHPDQGHGE\WKHUXOHVRISURFHGXUHVHFVXEVHF$R$UHTXLUHV
WKH2PEXGVPDQWRSUHVHQWWKHVHUHDVRQVLQDPDQQHUXQGHUVWDQGDEOHIRUDFRQVXPHU
7KH 2PEXGVPDQ KDV EHHQ SDUWLFXODUO\ VXFFHVVIXO LQ DGRSWLQJ D YHU\ WUDQVSDUHQW DQG
HDV\WRXQGHUVWDQGPRGHRIH[SODLQLQJWKHLQVXUDQFHODZWRFRPSODLQDQWVFSRÖMERLQ
VERSICHERUNGSOMBUDSMANN E.V.HGIQSSHWVHT
3URI'U-HQV*DO
41
WXUQWKHIRFXVRQH[SODLQLQJWRWKHOHJDOO\SUR¿FLHQWLQVXUHUWKH¿QHGHWDLOV
RIWKHUDWLRQDOHEHKLQGWKHGHFLVLRQ
7KH GHFLVLRQ ± WKLV LV WKH VSHFLDO IHDWXUH RI PDQ\ PRGHUQ RPEXGVPDQ
SURFHGXUHV DV RSSRVHG WR UHFRQFLOLDWLRQ SURFHGXUHV XWLOLVLQJ WKH QDPH
RI RPEXGVPDQ ± LV ELQGLQJ EXW RQ WKH UHVSRQGHQW LH WKH LQVXUDQFH
XQGHUWDNLQJVHFVXEVHF5R37KHFRPSODLQDQWLQUHWXUQLVQRWDW
DOOERXQGE\WKHGHFLVLRQEXWLVIUHHWREULQJKLVFODLPEHIRUHWKHFRPSHWHQW
FRXUWVVHFVXEVHFSKUDVH5R3,Q*HUPDQ\WKHUHLVVWLOOVRPH
XQFODULW\ZKDWWKLVPHDQVLQSUDFWLFH6RPHDXWKRUVKDYHIRUZDUGHGWKH
LGHDWKDWWKHGHFLVLRQRIDQ2PEXGVPDQPLJKWEHUHJDUGHGDVDQDUELWUDO
DZDUG ± RQO\ ELQGLQJ RQ WKH LQVXUDQFH XQGHUWDNLQJ ± WKXV JUDQWLQJ WKH
FRPSODLQDQWWKHULJKWWRVHHNGLUHFWH[HFXWLRQRIWKHDZDUGLIWKHLQVXUHU
VKRXOGQRWIUHHO\IXO¿OLWVREOLJDWLRQ1607KLVLQWHUSUHWDWLRQ±ZHOOIRXQGHGRU
QRW±KDVKRZHYHUEHHQUHMHFWHGE\WKHPDMRULW\RIVFKRODUV161,WDSSHDUV
WREHWKHSUHYDLOLQJRSLQLRQWKDWWKHGHFLVLRQRIWKH2PEXGVPDQLVHLWKHU
WREHTXDOL¿HGDVDSRVLWLYHRUQHJDWLYHDFNQRZOHGJPHQWRILQGHEWHGQHVV
±JUDQWHGE\WKHLQVXUHUE\DFFHGLQJWRWKHVXSSRUWRUJDQLVDWLRQXQGHUWKH
FRQGLWLRQWKDWDQGWRWKHH[WHQWWRZKLFKWKH2PEXGVPDQ¿QGVLQIDYRXU
RIWKHFRPSODLQDQW±RUDVDVXLJHQHULVGHFLVLRQKDYLQJWKHSURSHUWLHVRI
DQ DFNQRZOHGJHPHQW RI LQGHEWHGQHVV162 6KRXOG DQ LQVXUHU EH XQZLOOLQJ
WR FRQIRUP WR D GHFLVLRQ WKH FRPSODLQDQW FRXOG QRW GLUHFWO\ HQIRUFH WKH
GHFLVLRQEXWZRXOG¿UVWKDYHWRORGJHDFODLPRXWRIWKHGHFLVLRQLH
WKH DFNQRZOHGJPHQW RI LQGHEWHGQHVV EHIRUH WKH FRPSHWHQW FRXUW 7KH
LQVXUHU¶V RQO\ PHDQV RI GHIHQFH ZRXOG EH WR GHPRQVWUDWH WKH LQYDOLGLW\
RI WKH SVHXGR DFNQRZOHGJPHQW RI LQGHEWHGQHVV164 &RQFHUQLQJ WKH
JURXQGV RQ ZKLFK WKH LQVXUHU PD\ EDVH LWV DOOHJDWLRQ RI LQHIIHFWLYHQHVV
RIWKH2PEXGVPDQ¶VGHFLVLRQPRVWDXWKRUVZDQWWRDSSO\per analogiam
WKHJURXQGVRQZKLFKDQDUELWUDODZDUGPD\EHVHWDVLGHFSVHF
OMBUDSMANN
160
SCHLOSSER$OWHUQDWLYH6WUHLWEHLOHJXQJLQGHU.UHGLWZLUWVFKDIWLQ%DQNUHFKWOLFKH9HUHLQLJXQJ
+UVJ .DUWHQJHVWHXHUWHU =DKOXQJVYHUNHKU ± $XHUJHULFKWOLFKH 6WUHLWVFKOLFKWXQJ
%DQNUHFKWVWDJ%HUOLQDQG1HZ<RUNSS±DW JORDANS'HUUHFKWOLFKH
&KDUDNWHU YRQ 2PEXGVPDQQ6\VWHPHQ XQG LKUHQ (QWVFKHLGXQJHQ LQ 9HUEUDXFKHU XQG
5HFKWSS±DWet passim
161
HOERENIQSidemIQS V. HIPPELIQSS±HWVHTT
LORENZ IQ S V. RINTELEN LQ %HFNPDQQ0DWXVFKH%HFNPDQQ HGV IQ SDUDPRÖLSSLQidem0DUWLQHGV9HUVLFKHUXQJVYHUWUDJVJHVHW]thHG0XQLFK
9RUEHP , SDUD BERGER 6FKLHGVJHULFKWVEDUNHLW XQG %DQNHQJHVFKlIW ± (LQH
=HLWHQZHQGHLQ:0±=HLWVFKULIWIU:LUWVFKDIWVXQG%DQNHQUHFKWSS±
DWIQ
FÜR
VERSICHERUNGEN IQS
162
&Si.a. V. HIPPELIQSSHWVHTTHWVHT
V.
RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUD
164
V.
HIPPELIQS
42
*HUPDQ&RGHRI&LYLO3URFHGXUH7RJHQHUDONQRZOHGJHWKHUHKDVWKXV
IDUKRZHYHUQRWEHHQDVLQJOHLQVXUHUWRGLVUHJDUGDELQGLQJGHFLVLRQRI
WKH2PEXGVPDQ166,QVRIDUWKHTXHVWLRQRIKRZDFRPSODLQDQWVKRXOGUHDFW
LQVXFKDVLWXDWLRQLVPRUHRIDglass bead game167WKDQDSUHVVLQJQHHG
7KHGHFLVLRQZLOOXVXDOO\DZDUGWKHFRPSODLQDQWDFODLP,QWKLVGHFLVLRQ
ZLOODOVREHLQFOXGHGDFODLPIRULQWHUHVWZLWKWKHLQWHUHVWUDWHEHLQJWKH
VWDWXWRU\LQWHUHVWUDWHRIVHFRIWKH*HUPDQ&LYLO&RGHDQGWKHFODLP
EHDULQJ LQWHUHVW IURP WKH PRPHQW DW ZKLFK WKH FRPSODLQW ZDV UHFHLYHG
E\WKH2PEXGVPDQVHF5R37KHGHFLVLRQFDQKRZHYHUDOVREHD
GHFODUDWRU\GHFLVLRQE\VHWWLQJRXWHJWKDWWKHSROLF\KROGHULVQRWREOLJDWHG
WRUHIXQGDFHUWDLQDPRXQWRIEHQH¿WVUHFHLYHGE\WKHLQVXUHU7KLVGHFLVLRQ
ZRXOGDOVREHELQGLQJRQWKHLQVXUHUZKRZRXOGQRWEHDOORZHGWRSXUVXH
WKHFODLPLQFRXUW
,IWKHGHFLVLRQRQO\JUDQWVWKHFRPSODLQDQWDSDUWRIKLVFODLPKHUHPDLQV
IUHH WR SHWLWLRQ WKH FRXUWV WR JDLQ WKH UHVW 2WKHU WKDQ LQ VRPH IRUHLJQ
RPEXGVPDQ VFKHPHV VXFK DFWLRQ ZRXOG QRW DOWHU WKH IDFW WKDW WKH
GHFLVLRQ UHJDUGLQJ WKH SDUWLDO VXFFHVV UHPDLQV ELQGLQJ DQG PXVW EH
REVHUYHG E\ WKH LQVXUHU :KLOH RQH FRXOG WKLQN DERXW DSSO\LQJ WKH
SULQFLSOHRInon venire contra factum propriumVXFKGRHVQRWVHHPWREH
WKHFRQFHSWIDYRXUHGE\WKHUXOHVRISURFHGXUH6HFVXEVHFFDQG
5R3DUHDGDPDQWLQWKHLUSRVLWLRQWKDWDGHFLVLRQLVELQGLQJDQGUHPDLQV
ELQGLQJ RQ WKH UHVSRQGHQW ZKLOH OHDYLQJ WKH FRPSODLQDQW WKH SRVVLELOLW\
&SV. HIPPELIQSSHWVHTLORENZ IQSSHWVHT
166
V. RINTELEN LQ %HFNPDQQ0DWXVFKH%HFNPDQQ HGV IQ SDUD IQ 7KH
SLFWXUHLVGLIIHUHQWLQWKH8.ZKHUHRQHLQVXUHUSHWLWLRQHGWKH+LJK&RXUWWRVHWDVLGHD
GHFLVLRQRIWKH,QVXUDQFH2PEXGVPDQ%XUHDXLQ,QRegina v. Insurance Ombudsman
Bureau and the Insurance Ombudsmann ex parte Aegon Life Assurance Ltd. >@&/&
LWZDVKHOGWKDWWKH2PEXGVPDQ¶VGHFLVLRQVFRXOGQRWEHUHYLHZHGDWDOO8QGHUWKHQHZ
FRPSXOVRU\V\VWHPRIWKH)26VXFKLVQRORQJHUWUXHDQGOLPLWHGMXGLFLDOUHYLHZLVSRVVLEOH
DQGVFDUFHO\PDGHXVHRIE\LQVXUHUVFSHJSUMMER,,QVXUDQFH/DZDQGWKH)LQDQFLDO
2PEXGVPDQ6HUYLFH/RQGRQ SDUD
7KHLQYRFDWLRQRIWKHSLFWXUHRI+HUPDQ+HVVH¶VGlasperlenspielWRGHVFULEHWKHDWWHPSW
WR VROYH WKH SUREOHP RI WKH 2PEXGPDQ¶V GHFLVLRQV¶ ELQGLQJ HIIHFW ZDV ERUURZHG IURP
SCHLOSSER IQS
,WLVQRWHQWLUHO\FOHDULIWKLVSURYLVLRQOLPLWVWKHFRPSODLQDQWIURPFODLPLQJKLJKHULQWHUHVW
UDWHVZKHUHDSSOLFDEOHDQGSURYLQJWKDWWKHLQVXUHUZDVLQGHIDXOWDWDQHDUOLHUVWDJH
$FFRUGLQJWRWKHSRVLWLRQRIWKHSUHYDLOLQJRSLQLRQH[SODLQHGDERYHWKHLQVXUHUFRXOGLQ
IDFWSHWLWLRQWKHFRXUWEXWWKHSROLF\KROGHUFRXOGREMHFWWRWKHFODLPE\UDLVLQJWKHGHFLVLRQ
RIWKH2PEXGVPDQ
(JVHFRIWKH7HUPVRI5HIHUHQFHRIWKH$XVWUDOLDQ)26ZKLFKSURYLGHVWKDWIRUD
GHWHUPLQDWLRQDOVRIRUDUHFRPPHQGDWLRQWRKDYHLWVELQGLQJHIIHFWRQWKHLQVXUHUWKH
DSSOLFDQW KDV WR GHFODUH D UHOHDVH IURP OLDELOLW\ FRQFHUQLQJ DOO PDWWHUV LQYROYHG LQ WKH
GLVSXWH
V.
RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQHGV IQSDUD
3URI'U-HQV*DO
WRDOZD\VJREHIRUHWKHFRXUWV:KLOHRQHPD\KDYHGRXEWVLIWKLVLVDQ
HTXLWDEOHVROXWLRQLWUHPDLQVWUXH:LWKWKH2PEXGVPDQ¶VGHFLVLRQWKH
FRPSODLQDQWPD\KDYHKLVFDNHDQGHDWLWWRR
2. Non-Binding Recommendation
,QFDVHVLQZKLFKWKHDPRXQWLQGLVSXWHH[FHHGV¼EXWLVLQIHULRU
WR¼WKH2PEXGVPDQUHQGHUVDQRQELQGLQJUHFRPPHQGDWLRQ
6XFK D UHFRPPHQGDWLRQ FRQIRUPV WR WKH DERYH GHVFULEHG GHFLVLRQ LQ DOO
DVSHFWVVDYHLWVELQGLQJHIIHFW,WDOVRKDVWREHSDVVHGLQZULWLQJPXVW
FRQWDLQUHDVRQVDQGLVWREHWUDQVPLWWHGWRDOOSDUWLHVLPPHGLDWHO\VHF
VXEVHFSKUDVHVDQG5R3,WKRZHYHUELQGVQHLWKHUFRPSODLQDQWQRU
UHVSRQGHQWDQGKHUHWKHXQGHUWDNLQJLVIUHHWREULQJWKHFDVHEHIRUHWKH
FRXUWVVHFVXEVHFSKUDVH5R3DQGWRXVHDOOPHDQVRIGHIHQFH
DJDLQVWDFODLPEURXJKWE\WKHFRPSODLQDQWLQDFRXUWRIODZ
2QHFRXOGLQVRIDUEHOLHYHWKLVWREHDUDWKHUGXOOEODGH,WQHYHUWKHOHVVKDV
SURYHQWREHTXLWHDQHIIHFWLYHRQH±ZKLFKZLOORIFRXUVHGHSHQGRQWKH
2PEXGVPDQ¶VSHUVXDVLYHQHVVDQGWKHLQGXVWU\¶VZLOOLQJQHVVWRUDWKHUVHWWOH
GLVSXWHVWKDQGUDJWKHPRXWLQGH¿QLWHO\,QVXUHUVKDYHDOPRVWZLWKRXWIDLO
FRQIRUPHGWKHLUDFWLRQVWRVXFKUHFRPPHQGDWLRQV
3. Publication
,Q RUGHU WR HOXGH WKH UHSURDFK RI SUDFWLFLQJ closed-door MXVWLFH the
2PEXGVPDQ VKRXOG QRW RQO\ WU\ WR FUHDWH WUDQVSDUHQF\ UHJDUGLQJ LWV
SURFHGXUH SXEOLVK UHSRUWV VHHN RXW FRQWDFW ZLWK WKH SXEOLF EXW DOVR
SXEOLVK KLV GHFLVLRQV DQG UHFRPPHQGDWLRQV 6XFK D SXEOLFDWLRQ ZLOO DOVR
KDYH WKH DGGHG EHQH¿W RI SURYLGLQJ QHZ LPSXOVHV IRU WKH GHYHORSPHQW
RI WKH LQVXUDQFH ODZ 7KH 2PEXGVPDQ LV DOORZHG WR DQG GRHV SXEOLVK
LQ DQ DQRQ\PLVHG PDQQHU VXFK LV DOVR WKH QRUP IRU WKH SXEOLFDWLRQ RI
FRXUWGHFLVLRQVLQ*HUPDQ\VHOHFWHGGHFLVLRQVDQGUHFRPPHQGDWLRQVRQ
KLVZHEVLWH
(VSFULWLFDOV. HIPPELIQS
7KLVLVWKHH[FHVVDPRXQWLQGLVSXWHDERYHZKLFKWKH2PEXGVPDQODFNVMXULVGLFWLRQFS
VXSUDFK9D
RÖMERIQSIQ
7KLVZDVDUHSURDFKPDGHDJDLQVWWKH3ULYDWH%DQNLQJ2PEXGVPDQRQDUHJXODUEDVLVGXH
WRKLVUHVHUYDWLRQWRSXEOLVKDQ\PDWHULDOVFSSCHERPE IQSIQ
,QWKLVGLUHFWLRQDOVRSCHERPE IQS
OMBUDSMANN FÜR VERSICHERUNGEN IQSV. RINTELENLQ%HFNPDQQ0DWXVFKH%HFNPDQQ
HGV IQSDUDKDVQHYHUWKHOHVVVWDWHGWKDWWKHUHLVURRPIRULPSURYHPHQWHJ
V\VWHPDWLFSXEOLFDWLRQRIDOOGHFLVLRQV
44
VIII. Conclusion
:LWK WKH HVWDEOLVKPHQW RI WKH Versicherungsombudsmann WKH *HUPDQ
LQVXUDQFH LQGXVWU\ ZDV DEOH WR VTXDUH WKH FLUFOH LW EHLQJ DQ LQVWLWXWLRQ
WKDW LV FKHULVKHG E\ ERWK WKH XQGHUWDNLQJV DQG WKH FXVWRPHUV $W ¿UVW
VLJKWWKLVPLJKWEHVXUSULVLQJ2YHUDWKLUGRIDOOFRPSODLQWVDUHGLVPLVVHG
DV LQDGPLVVLEOH DQG RI WKH UHPDLQLQJ FRPSODLQWV RQO\ D URXJK WKLUG LV
GHFLGHGDWOHDVWSDUWLDOO\LQWKHFRPSODLQDQW¶VIDYRXU7KLVQRWRYHUO\
LPSUHVVLYHVXFFHVVUDWHIRUFRQVXPHUVLVKRZHYHUDOVRDQLQGLFDWLRQIRU
WKHVXFFHVVRIWKH2PEXGVPDQ,WVPHUHH[LVWHQFHKDVLQGXFHGLQVXUHUV
WRHQKDQFHWKHLULQWHUQDOFRPSODLQWVKDQGOLQJZKLFKKDVLQWXUQGHFUHDVHG
WKHDPRXQWRI³ZURQJ´GHFLVLRQV0RVWLPSRUWDQWO\WKHVXFFHVVRIWKH
2PEXGVPDQFDQQRWEHPHDVXUHGE\RQO\WXUQLQJWRWKHKDUGQXPEHUV,WV
PRVWDPELWLRXVJRDOLVWRGHIXVHGLVSXWHVDQGDPHOLRUDWHWKHUHODWLRQVKLS
EHWZHHQ LQVXUHUV DQG WKHLU FXVWRPHUV $V RQH FRPSODLQDQW KDV SXW LW LQ
DOHWWHURIWKDQNV³HYHQWKRXJKP\FRPSODLQWDJDLQVW>@ZDVQRWPHW
ZLWK VXFFHVV P\ ZLIH DQG , ZRXOG OLNH WR WKDQN \RX IRU \RXU DVVLGXRXV
H[DPLQDWLRQ >RI RXU FDVH@ <RXU GHWDLOHG UHDVRQLQJ KDV PDGH XV UHDOLVH
WKDW P\ LQVXUDQFH ZDV LQ WKH ULJKW WR UHIXVH´ ,I VXFK D VWDWHPHQW LV
LQGLFDWLYH RI WKH VHQWLPHQWV RI RQO\ D SRUWLRQ RI WKH FRPSODLQDQWV ZKLFK
ZHUH³XQVXFFHVVIXO´WKH2PEXGVPDQLVWUXO\DVXFFHVV
OMBUDSMANN FÜR VERSICHERUNGEN IQSIRUDQH[SODQDWLRQZK\WKLVQXPEHULVQRWDV
GUDPDWLFDVLWPLJKWDSSHDUVHHVXSUDIQ
OMBUDSMANN
FÜR
VERSICHERUNGEN IQSS
&S DOEHLW FRQFHUQLQJ WKH %DQNLQJ 2PEXGVPDQ V. HIPPEL IQ S ZLWK IXUWKHU
UHIHUHQFHV
7DNHQIURPWKHFRUUHVSRQGHQFHLQWKHFDVHZLWKWKHGRFNHWQXPEHU0UHSULQWHG
in VERSICHERUNGSOMBUDSMANN E.V.HGIQS
Alternative Dispute
Resolution Systems for Insurance
Disputes - An Australian Perspective
Christopher Rodd
B.Juris, LLB, Grad Dip Ins Law, ANZIIF (Fellow)
7KH DXWKRU LV FXUUHQWO\ 7HFKQLFDO &RXQVHO IRU &*8 ,QVXUDQFH /LPLWHG LQ 0HOERXUQH
$XVWUDOLDDQGLVDOVRD6HQLRU)HOORZLQWKH/DZ)DFXOW\0RQDVK8QLYHUVLW\ZKHUHKH
lectures in insurance law part time. He has been both a state and national president of
$,/$$XVWUDOLDQ,QVXUDQFH/DZ$VVRFLDWLRQWKH$XVWUDOLDQ&KDSWHURI$,'$
7KHDXWKRULVDOVRDQDFWLYHPHPEHURI$,'$ZRUNLQJSDUWLHV&OLPDWH&KDQJHDQG
,QVXUDQFHDQG$OWHUQDWLYH'LVSXWH5HVROXWLRQLQ,QVXUDQFH
7KHUHFLSLHQWRIWKH$XVWUDOLDQ,QVXUDQFH/DZ3UL]HWKHDXWKRUPDLQWDLQVDQDFWLYH
involvement in insurance law education, and has written numerous articles on insurance
ODZDQGLQVXUDQFHUHODWHGLVVXHV+HLVDOVRDQLQWHUQDWLRQDOPHPEHURIWKH86$EDVHG
RUJDQLVDWLRQ)'&&)HGHUDWLRQRI'HIHQFHDQG&RUSRUDWH&RXQVHO
,QVXUDQFHGLVSXWHVLQ$XVWUDOLDFDQEHUHVROYHGLQDQXPEHURIZD\V
/LWLJDWLRQZLWKRUZLWKRXWPHGLDWLRQDQGDUELWUDWLRQ
0HGLDWLRQ
$UELWUDWLRQ
7KH)LQDQFLDO2PEXGVPDQ6HUYLFH)26
7KHDXWKRUZLOOIRFXVSULPDULO\RQRSWLRQIRXU
7KHH[WHUQDOPHFKDQLVPIRUWKHUHVROXWLRQRIWKHYDVWPDMRULW\RILQVXUDQFH
UHODWHGFRQVXPHUGLVSXWHVLQ$XVWUDOLDLVWKH)LQDQFLDO2PEXGVPDQ6HUYLFH
7KLV LQGXVWU\ LQLWLDWLYH ZDV LQWURGXFHG LQ DQG DW WKDW VWDJH ZDV
UHIHUUHG WR DV WKH *HQHUDO ,QVXUDQFH (QTXLULHV DQG &RPSODLQWV 6FKHPH
*,(&6 ,W ZDV HVWDEOLVKHG LQ UHVSRQVH WR ZKDW ZDV FRQVLGHUHG WR EH D
GHPRQVWUDWHGQHHGIRUDQLQGHSHQGHQWPHFKDQLVPIRUWKHDGMXGLFDWLRQDQG
UHVROXWLRQRIFRQVXPHUFRPSODLQWVDQGGLVSXWHVZLWKLQVXUDQFHFRPSDQLHV
)URPWKHRXWVHWLWZDVLQWHQGHGWKDWWKHVFKHPHZRXOGEHIUHHWRFRQVXPHUV1
1
8QLQVXUHG PRWRULVWV FRXOG DFFHVV WKH VFKHPH XSRQ SD\PHQW RI D VPDOO IHH SURYLGHG
WKDWWKHFODLPDJDLQVWDQLQVXUHU¶VFXVWRPHUGLGQRWH[FHHGDGHVLJQDWHGVXPZKLFKKDV
JUDGXDOO\LQFUHDVHGVLQFHLWVLQLWLDOLQWURGXFWLRQDQGLVFXUUHQWO\7KHUHTXLUHPHQW
WRSD\DIHHKDVVLQFHEHHQDEROLVKHG
46
$OWHUQDWLYH'LVSXWH5HVROXWLRQ6\VWHPVIRU,QVXUDQFH'LVSXWHV«
DQGZRXOGSURGXFHDQRXWFRPHWKDWZRXOGEHELQGLQJRQLQVXUHUVEXWQRW
RQFRQVXPHUV$FRQVXPHUGLVVDWLV¿HGZLWKDGHFLVLRQZRXOGUHPDLQIUHH
WRSXUVXHDUHPHG\WKURXJKWUDGLWLRQDOPHFKDQLVPVVXFKDVOLWLJDWLRQ
7KHVFKHPHZDVWKHQDQGUHPDLQVWRWKLVGD\IXOO\IXQGHGE\LQGXVWU\
7KHLQLWLDOPHFKDQLVPRIIXQGLQJZDVWKHSD\PHQWRIDIHHFDOFXODWHGRQ
WKHEDVLVRIDQLQVXUHU¶VSHUFHQWDJHRIPDUNHWVKDUHSOXVWKHSD\PHQWRID
IHHIRUVHUYLFHGHSHQGHQWXSRQWKHVWDJHDWZKLFKDPDWWHUZDVUHVROYHG
:KHQ¿UVWLQWURGXFHGWKHIHHIRUVHUYLFHFKDUJHGWRDQLQVXUHUZDVORZHULI
WKHLQVXUHUZDVVXFFHVVIXOLQGHIHQGLQJLWVGHFLVLRQLQUHODWLRQWRDGLVSXWH
7KHIHHVWUXFWXUHZDVVXEVHTXHQWO\FKDQJHGVRWKDWWKH³VXFFHVVIHH´ZDV
VFUDSSHGLQIDYRXURID³IHHIRUVHUYLFH´VFKHPHEXWZLWKDVXEVWDQWLDOO\
ORZHUPHPEHUVKLSOHY\WKDWLVPRUH³XVHUSD\V´
,QWKH*,(&6ZDVLQFRUSRUDWHGDVDVHOIUHJXODWLRQPHFKDQLVPZLWK
SULPDU\WDVNV
7KHDGPLQLVWUDWLRQRI,QVXUDQFH(QTXLULHVDQG&RPSODLQWV/LPLWHG,(&
0RQLWRULQJ LQVXUHU FRPSOLDQFH ZLWK WKH *HQHUDO ,QVXUDQFH &RGH RI
Practice
5HVROXWLRQRIGLVSXWHVEHWZHHQLQVXUHUVDQGFRQVXPHUVDQG
0RQLWRULQJ WKH LQGXVWU\¶V LPSOHPHQWDWLRQ DQG FRPSOLDQFH ZLWK WKH
JHQHUDOLQVXUDQFHLQIRUPDWLRQSULYDF\SULQFLSOHV
6XEVHTXHQWO\ LQ WKH *,(&6 PHUJHG ZLWK ,(& WR IRUP D QHZ
DGPLQLVWUDWLYHERG\NQRZQDVWKH,QVXUDQFH2PEXGVPDQ6HUYLFH,26
)LQDOO\IROORZLQJWKHPHUJHURIWKUHHVHSDUDWHVFKHPHV%DQNLQJ/LIHDQG
6XSHUDQQXDWLRQDQG*HQHUDO,QVXUDQFHWKHFXUUHQW)LQDQFLDO2PEXGVPDQ
6FKHPH)26ZDVIRUPHG7KLVRFFXUUHGLQDQGLWLVQRZWKHERG\
YHVWHG ZLWK UHVSRQVLELOLW\ WR UHVROYH GLVSXWHV EHWZHHQ ¿QDQFLDO VHUYLFH
SURYLGHUV LQFOXGLQJ LQVXUDQFH EURNHUV DQG DXWKRULVHG IRUHLJQ LQVXUHUV
RSHUDWLQJLQ$XVWUDOLDDQGFRQVXPHUV
7KHSULQFLSOHVWKDWXQGHUSLQWKHRSHUDWLRQRIWKH)26DUHRXWOLQHGLQWKH
VFKHPH¶V7HUPVRI5HIHUHQFH725
,QGHDOLQJZLWKDGLVSXWHWKH)26
DPXVW GR ZKDW LQ LWV RSLQLRQ LV DSSURSULDWH ZLWK D YLHZ WR UHVROYLQJ
GLVSXWHVLQDFRRSHUDWLYHHI¿FLHQWWLPHO\DQGIDLUPDQQHU
EVKDOOSURFHHGZLWKDPLQLPXPRIIRUPDOLW\DQGWHFKQLFDOLW\DQG
F VKDOOEHDVWUDQVSDUHQWDVSRVVLEOHZKLOVWDFWLQJLQDFFRUGDQFHZLWKLWV
FRQ¿GHQWLDOLW\DQGSULYDF\REOLJDWLRQV2
2
3DUD)LQDQFLDO2PEXGVPDQ6HUYLFH7HUPVRI5HIHUHQFH-DQXDU\DVDPHQGHG
-DQXDU\
&KULVWRSKHU5RGG
'HFLVLRQV DUH PDGH E\ ZD\ RI HLWKHU D 5HFRPPHQGDWLRQ ZKLFK LV QRW
ELQGLQJRQHLWKHUWKH¿QDQFLDOVHUYLFHSURYLGHURUWKHFRQVXPHURUE\ZD\
RID'HWHUPLQDWLRQZKLFKLVELQGLQJRQWKH¿QDQFLDOVHUYLFHSURYLGHUEXW
QRWRQWKHFRQVXPHU7KHUHLVDOVRDSURFHVVRIFRQFLOLDWLRQ7KLVLQYROYHV
DQ)26FDVHPDQDJHUZRUNLQJZLWKERWKWKHLQVXUHUDQGWKHDSSOLFDQWWR
DFKLHYHDFRQVHQVXVYLHZDQGDFFRUGLQJO\UHVROYHWKHGLVSXWH$FRQFLOLDWHG
RXWFRPHDFKLHYHGLVELQGLQJRQERWKSDUWLHV
7KH MXULVGLFWLRQ RI WKH )26 LQ WKH FRQWH[W RI LQVXUDQFH LV FRQ¿QHG WR
GLVSXWHVWKDWDULVHIURPDFRQWUDFWRUREOLJDWLRQDULVLQJXQGHU$XVWUDOLDQ
ODZDQGWKDWUHODWHVWRLQWHUDOLD
LLL DQHQWLWOHPHQWRUEHQH¿WXQGHUDOLIHLQVXUDQFHSROLF\E\DSHUVRQ
ZKRLVVSHFL¿HGRUUHIHUUHGWRLQWKHOLIHLQVXUDQFHSROLF\ZKHWKHUE\
QDPHRURWKHUZLVHWRZKRPWKHLQVXUDQFHFRYHUH[WHQGVRUWRZKRP
PRQH\EHFRPHVSD\DEOHXQGHUWKHOLIHLQVXUDQFHSROLF\
LY DQHQWLWOHPHQWRUEHQH¿WXQGHUDJHQHUDOLQVXUDQFHSROLF\E\DSHUVRQ
ZKR LV VSHFL¿HG RU UHIHUUHG WR LQ WKH SROLF\ ZKHWKHU E\ QDPH RU
RWKHUZLVHDVDSHUVRQWRZKRPWKHSROLF\H[WHQGV
YL D FODLP XQGHU DQRWKHU SHUVRQ¶V PRWRU YHKLFOH LQVXUDQFH SROLF\ IRU
SURSHUW\ GDPDJH WR DQ XQLQVXUHG PRWRU YHKLFOH E\ D GULYHU RI WKH
XQLQVXUHGYHKLFOH±EXWRQO\ZKHUHDYDOLGFODLPKDVEHHQORGJHGE\
WKHRZQHURIWKHLQVXUHGYHKLFOHDQGDQ\UHOHYDQWH[FHVVSDLG4
7KH)26LVDOVRFRQ¿QHGWRKHDULQJGLVSXWHVWKDWUHODWHWRUHWDLOLQVXUDQFH
SROLFLHVUHVLGHQWLDOVWUDWDWLWOHLQVXUDQFHSURGXFWVVPDOOEXVLQHVVLQVXUDQFH
SURGXFWVDQGPHGLFDOLQGHPQLW\LQVXUDQFHSURGXFWVDQGFDQQRWFRQVLGHU
LQVXUDQFHGLVSXWHV
DERXWWKHOHYHORIDIHHSUHPLXPFKDUJHGRULQWHUHVWUDWHVXEMHFWWR
VRPHTXDOL¿FDWLRQV
DERXW XQGHUZULWLQJ RU DFWXDULDO IDFWRUV OHDGLQJ WR DQ RIIHU RI D OLIH
LQVXUDQFHSROLF\RQQRQVWDQGDUGWHUPV
LQWKHFDVHRIDGLVSXWHDERXWDJHQHUDOLQVXUDQFHSROLF\±DERXWUDWLQJ
IDFWRUV DQG ZHLJKWLQJV WKH LQVXUHU DSSOLHV WR GHWHUPLQH WKH LQVXUHG¶V
RU SURSRVHG LQVXUHG¶V EDVH SUHPLXP ZKLFK LV FRPPHUFLDOO\ VHQVLWLYH
LQIRUPDWLRQ
DERXWDGHFLVLRQWRUHIXVHWRSURYLGHLQVXUDQFHFRYHUVXEMHFWWRVRPH
TXDOL¿FDWLRQV
WKDW KDV DOUHDG\ EHHQ GHDOW ZLWK E\ D FRXUW RU GLVSXWH UHVROXWLRQ
WULEXQDO HVWDEOLVKHG E\ OHJLVODWLRQ RU E\ DQRWKHU H[WHUQDO GLVSXWH
,ELG3DUD
4
,ELG3DUDE
UHVROXWLRQVFKHPHDSSURYHGE\WKH$XVWUDOLDQ6HFXULWLHVDQG,QYHVWPHQW
&RPPLVVLRQ$6,&
LQ UHODWLRQ WR ZKLFK WKH FRQVXPHU KDV FRPPHQFHG OHJDO SURFHHGLQJV
EHIRUHWKHGLVSXWHZDVORGJHGZLWK)26VXEMHFWWRFHUWDLQTXDOL¿FDWLRQV
RU KDV EHHQ ORGJHG ZLWK DQRWKHU $6,& DSSURYHG H[WHUQDO GLVSXWH
UHVROXWLRQVFKHPH
ZKHUH WKH YDOXH RI WKH $SSOLFDQW¶V FRQVXPHU¶V FODLP LQ WKH GLVSXWH
H[FHHGV
:KHUH WKH DSSOLFDQW FRQVXPHU LV D PHPEHU RI D JURXS RI UHODWHG
ERGLHVFRUSRUDWHDQGWKDWJURXSKDVLQH[FHVVRIHPSOR\HHVRU
HPSOR\HHVLQWKHFDVHRIDPDQXIDFWXULQJJURXS
7KHUHDUHDOVRDQXPEHURIFLUFXPVWDQFHVLQZKLFKWKH)26PD\H[HUFLVHD
GLVFUHWLRQWRGHFOLQHWRDGMXGLFDWHDGLVSXWHVXFKDVLQLQVWDQFHVZKHUHD
GLVSXWHLVIULYRORXVYH[DWLRXVRUODFNLQJLQVXEVWDQFHRUZKHUHWKHGLVSXWH
UHODWHVWRD¿QDQFLDOVHUYLFHSURYLGHU¶VSUDFWLFHVRUSROLFLHVDQGGRHVQRW
LQYROYHDQ\DOOHJDWLRQRIPDODGPLQLVWUDWLRQRULQDSSURSULDWHDSSOLFDWLRQRI
SUDFWLFHRUSROLF\
:KLOHWKHUHDUHWLPHFRQVWUDLQWVLQUHVSHFWRIPDWWHUVZLWKLQWKHMXULVGLFWLRQ
RI)26WKHWLPHOLPLWV DUHJHQHURXVLQWHUPVRIFRQVXPHUDFFHVV7KH
)26 ZLOO KHDU D GLVSXWH SURYLGHG LW LV UHIHUUHG WR )26 ZLWKLQ \HDUV RI
WKH ¿QDO GHFLVLRQ RI DQ LQVXUHU¶V ,QWHUQDO 'LVSXWH 5HVROXWLRQ SURFHVV ,Q
DOORWKHUFLUFXPVWDQFHVZLWKLQ\HDUVRIWKHGDWHZKHQWKH$SSOLFDQW
FRQVXPHU³¿UVWEHFDPHDZDUHRUVKRXOGUHDVRQDEO\KDYHEHFRPHDZDUH
WKDWWKH\VXIIHUHGWKHORVV´6,QDGGLWLRQKRZHYHUWKH)26UHWDLQVDQ
RYHUDUFKLQJDXWKRULW\XQGHULWV725WR³FRQVLGHUDGLVSXWHDIWHUWKHVHWLPH
OLPLWVLI)26FRQVLGHUVWKDWH[FHSWLRQDOFLUFXPVWDQFHVDSSO\´ There is no
JXLGDQFHDVWRZKDWFRQVWLWXWHV³H[FHSWLRQDOFLUFXPVWDQFHV´
2QFH D 'LVSXWH LV UDLVHG WKHUH DUH WLJKW WLPH FRQVWUDLQWV LPSRVHG RQ D
)63)LQDQFLDO6HUYLFH3URYLGHU,QVXUHUWRUHVSRQGDQGDIDLOXUHWRGR
VRFDQUHVXOWLQD'HWHUPLQDWLRQEHLQJKDQGHGGRZQE\)26LQIDYRXURID
FRQVXPHUZLWKRXWWKHEHQH¿WRIWKHLQVXUHU¶VVXEPLVVLRQ
7KH725SUHVFULEHVYHU\EURDGSRZHUVLQUHVSHFWRIWKH)26¶VFDSDFLW\WR
UHTXLUHWKHSURYLVLRQRILQIRUPDWLRQE\WKH)63,QVXUHUDQGDFRQVXPHU
³DQ\ LQIRUPDWLRQ WKH )26 FRQVLGHUV QHFHVVDU\´ H[FHSW ZKHUH D SDUW\
VDWLV¿HV WKH )26 WKDW WR FRPSO\ ZRXOG EUHDFK D GXW\ RI FRQ¿GHQWLDOLW\
,ELG3DUD
6
,ELG3DUDEL
,ELG
,ELG3DUD
&KULVWRSKHU5RGG
WRD7KLUG3DUW\ZRXOGEUHDFKDFRXUWRUGHURUSUHMXGLFHDFXUUHQWSROLFH
LQYHVWLJDWLRQ RU ZKHUH WKH LQIRUPDWLRQ HLWKHU QR ORQJHU H[LVWV RU LV QRW
ZLWKLQDSDUW\¶VUHDVRQDEOHSRVVHVVLRQWRFRQWURO
6LPLODUO\WKH725HPSRZHUVWKH)26WRGLUHFWDSDUW\WRDWWHQGDQLQWHUYLHZ
RULWFDQGLUHFWDQ)63WRDSSRLQWDQH[SHUWWRSURYLGHDUHSRUW10
,QPDNLQJDGHFLVLRQWKH)26LVQRWERXQGE\RUFRQVWUDLQHGE\DQ\UXOH
RIHYLGHQFH,QGHHGWKHFULWHULDIRUGHFLVLRQPDNLQJDUH
³:KHQGHFLGLQJDGLVSXWHDQGZKHWKHUDUHPHG\VKRXOGEHSURYLGHGLQ
DFFRUGDQFHZLWKSDUD)26ZLOOGRZKDWLQLWVRSLQLRQLVIDLUDQGUHDVRQDEOH
LQDOOWKHFLUFXPVWDQFHVKDYLQJUHJDUGWRHDFKRIWKHIROORZLQJ
DOHJDOSULQFLSOHV
EDSSOLFDEOHLQGXVWU\FRGHVRUJXLGDQFHDVWRSUDFWLFH
F JRRGLQGXVWU\SUDFWLFHDQG
GSUHYLRXVUHOHYDQWGHFLVLRQVRI)26RUD3UHGHFHVVRU6FKHPHDOWKRXJK
)26ZLOOQRWEHERXQGE\WKHVH
7KH¿QDOFULWHULRQUHPDLQVDVRXUFHRIFRQWHQWLRQIRUPDQ\LQVXUHUVDQG
RWKHU )63V DV LW FUHDWHV WKH SRWHQWLDO IRU D OHYHO RI LQFRQVLVWHQF\ DQG
XQFHUWDLQW\GHVSLWHZKDWPD\DPRXQWWRVLPLODUIDFWVLWXDWLRQV7KLVLQ
WXUQPDNHVLWGLI¿FXOWWRWUDLQVWDIIDQGHQVXUHDFRQVLVWHQF\RIDSSURDFK
SDUWLFXODUO\IRULQVXUHUVDGPLQLVWHULQJYROXPHFODLPV'HFLVLRQVIURP)26
WKDWDSSHDULUUHFRQFLODEO\DWRGGVZLWKSULRUGHFLVLRQVFDQDQGGRDULVH
'HFLVLRQPDNLQJLVEDVHGRQZULWWHQVXEPLVVLRQVIURPERWKVLGHV,QPRVW
LQVWDQFHVIROORZLQJWKHUHFHLSWRIZULWWHQVXEPLVVLRQVWKH)26ZLOOLVVXHD
³5HFRPPHQGDWLRQ´7KHSDUWLHVKDYHGD\VWRDFFHSWD5HFRPPHQGDWLRQ
DQGLIWKH\GRWKHGLVSXWHLVUHVROYHG$5HFRPPHQGDWLRQLVZULWWHQE\
WKH UHOHYDQW FDVH PDQDJHU DQG GRHV QRW LQYROYH WKH SDUWLFLSDWLRQ RI DQ
2PEXGVPDQWKH)63GRHVQRWDFFHSWWKH5HFRPPHQGDWLRQRUHLWKHUSDUW\
DVNVWKDWWKHPDWWHUSURFHHGWRD³'HWHUPLQDWLRQ´WKHPDWWHUZLOOSURFHHG
WR D 'HWHUPLQDWLRQ IURP DQ 2PEXGVPDQ RU DQ 2PEXGVPDQ¶V 3DQHO DQ
2PEXGVPDQDFRQVXPHUUHSUHVHQWDWLYHDQGDQLQGXVWU\UHSUHVHQWDWLYH
,QVRPHFDVHVLQYROYLQJKLJKYDOXHFODLPVGLVSXWHVRUVLJQL¿FDQWOHJDORU
LQGXVWU\ LVVXHV WKH GLVSXWH FDQ SURFHHG GLUHFW WR 'HWHUPLQDWLRQ ZLWKRXW
WKHLVVXDQFHRID5HFRPPHQGDWLRQ11
,QDQ\HYHQWWKHRXWFRPHLVQRWELQGLQJRQD&ODLPDQW5HPHGLHVRSHQWR
)26XQGHULWV725LQFOXGH
,ELG3DUD
10
,ELG3DUD
11
,ELG3DUD
DWKHSD\PHQWRIDVXPRIPRQH\
EWKHIRUJLYHQHVVRUYDULDWLRQRIDGHEW
F WKHUHOHDVHRIVHFXULW\IRUGHEW
GWKHUHSD\PHQWZDLYHURUYDULDWLRQRIDIHHRURWKHUDPRXQWSDLGWRRU
RZLQJWRWKH)LQDQFLDO6HUYLFHV3URYLGHURUWRLWVUHSUHVHQWDWLYHRUDJHQW
LQFOXGLQJWKHYDULDWLRQLQWKHDSSOLFDEOHLQWHUHVWUDWHRQDORDQ
HWKHUHLQVWDWHPHQWRUUHFWL¿FDWLRQRIDFRQWUDFW
I WKH YDULDWLRQ RI WKH WHUPV RI D &UHGLW &RQWUDFW LQ FDVHV RI ¿QDQFLDO
KDUGVKLS
JWKH PHHWLQJ RI D FODLP XQGHU DQ LQVXUDQFH SROLF\ E\ IRU H[DPSOH
UHSDLULQJUHLQVWDWLQJRUUHSODFLQJLWHPVRISURSHUW\DQG
KLQWKHFDVHRID'LVSXWHLQYROYLQJDSULYDF\LVVXHZLWKDQLQGLYLGXDO
WKDWWKH)LQDQFLDO6HUYLFHV3URYLGHUVKRXOGQRWUHSHDWFRQGXFWRQWKH
EDVLVWKDWLWFRQVWLWXWHVDQLQWHUIHUHQFHZLWKWKHSULYDF\RIDQLQGLYLGXDO
RUWKDWWKH)LQDQFLDO6HUYLFHV3URYLGHUVKRXOGFRUUHFWDGGWRRUGHOHWH
LQIRUPDWLRQSHUWDLQLQJWRWKH$SSOLFDQW12
7KH)26DOVRKDVWKHSRZHUWRRUGHUWKDWDQ)63FRPSHQVDWHWKHFODLPDQW
XSWRDPD[LPXPRI³IRUFRQVHTXHQWLDO¿QDQFLDOORVVRUGDPDJH´
ZKLFKLQHVVHQFHPHDQVWKDWWKH)26FDQRUGHUDQLQVXUHURURWKHU)63WR
SD\OLPLWHG³JHQHUDOGDPDJHV´+RZHYHUWKH)26FDQQRWRUGHUWKHSD\PHQW
RIGDPDJHVRIWKLVQDWXUHLIWKHJHQHUDOLQVXUDQFHSROLF\H[SUHVVO\H[FOXGHV
LW7KHSD\PHQWLVXSWRIRU³FRQVHTXHQWLDO¿QDQFLDOORVV´SOXVXS
WRIRU³QRQ¿QDQFLDOORVV´,WFDQDOVRRUGHUWKH)63WR³FRQWULEXWH
WR RWKHU OHJDO RU RWKHU SURIHVVLRQDO FRVWV RU WUDYHO FRVWV LQFXUUHG E\ DQ
$SSOLFDQW XS WR D PD[LPXP RI ´14 +RZHYHU LW FDQQRW RUGHU WKH
SD\PHQWRI³SXQLWLYHH[HPSODU\RUDJJUDYDWHGGDPDJHV´7KH\FDQDOVR
PDNHDQRUGHUIRUWKHSD\PHQWRILQWHUHVW
7KHUH UHPDLQV LQ WKH 725 DQ XQXWLOLVHG SURYLVLRQ WKDW KDV EHHQ LQ
H[LVWHQFHVLQFHLQFHSWLRQLQWKHV7KLVSURYLVLRQUHODWHVWR³7HVW&DVH
3URFHGXUHV´
$Q)63FDQUHTXHVWWKDW)26DEVWDLQIURPDGMXGLFDWLQJDGLVSXWHRQWKH
basis that the case involves:
³DQ LVVXH ZKLFK PD\ KDYH LPSRUWDQW FRQVHTXHQFHV IRU WKH EXVLQHVV RI
12
,ELG3DUD
,ELG3DUDD
14
,ELG3DUD
&KULVWRSKHU5RGG
WKH )63 RU )63V JHQHUDOO\ RU DQ LPSRUWDQW SRLQW RI ODZ´ There are
WLJKW UHVWULFWLRQV RQ WKH DELOLW\ RI DQ )63 WR SDUWLFLSDWH LQ WKH SURFHVV
LQFOXGLQJWKHLQVXUHU¶V)63¶VREOLJDWLRQWRPHHWLWVRZQOHJDOFRVWVRIWKH
WHVWFDVHDQGWKHDSSOLFDQW¶VFRVWLQFOXGLQJDQ\FRVWVLQYROYHGLQDQDSSHDO
VXFFHVVIXORURWKHUZLVH+RZHYHUWKDWVDLGWKHDXWKRULVXQDZDUHRIDQ\
FLUFXPVWDQFHLQZKLFKDQLQVXUHUKDVHYHUVRXJKWWRLQYRNHWKHSURYLVLRQ
,Q DQ DWWHPSW WR UHVROYH D GLVSXWH WKH )26 LV HQWLWOHG WR FDOO XSRQ WKH
SDUWLFLSDQWVWRFRQVLGHUQHJRWLDWLRQFRQFLOLDWLRQRUPHGLDWLRQ
,QDGGLWLRQWRWKHFDSDFLW\RIWKH)26WRDGMXGLFDWHFODLPVUHODWHGGLVSXWHV
LWFDQLQWHUYHQHLQFDVHVLQZKLFKDQLQVXUHUKDVGHFOLQHGWRLQVXUHKDV
LPSRVHG KDUVKHU WHUPV H[FHVV GHGXFWLEOH SUHPLXP HWF EXW RQO\ LQ
LQVWDQFHVLQZKLFKLWLVHVWDEOLVKHGWKDWWKHLQVXUHUKDVGRQHVRIRULQWHU
DOLD DQ LPSURSHU SXUSRVH ,W FDQ DOVR LQWHUYHQH LQ FDVHV LQYROYLQJ GHEW
FROOHFWLRQE\DQ)63VXFKDVFLUFXPVWDQFHVLQZKLFKDQLQVXUHULVSXUVXLQJ
SD\PHQWRIDSUHPLXPRUH[FHVVRULVH[HUFLVLQJDULJKWRIVXEURJDWLRQ
8SRQUHFHLSWRIDUHTXHVWIURPDQ$SSOLFDQWWRLQWHUYHQHWKH)26FDQRUGHU
DVWD\RISURFHHGLQJVXQWLOWKHPDWWHUKDVEHHQGHWHUPLQHGE\)267KLV
VWD\LQFOXGHVDGLUHFWLRQWRWKH)63WRWDNHQRIXUWKHUDFWLRQ³WRUHFRYHUD
GHEWWKHVXEMHFWRIWKHGLVSXWHWRSURWHFWDQ\DVVHWVVHFXULQJWKDWGHEW
RUWRDVVLJQDQ\ULJKWWRUHFRYHUWKDWGHEW´16
7KH )26 DQG LWV VWDII HQMR\ LPPXQLW\ IURP OLDELOLW\ LQ WKH SHUIRUPDQFH
RI WKHLU IXQFWLRQV DQG $SSOLFDQWV DUH SURWHFWHG IURP DQ\ GHIDPDWLRQ
SURFHHGLQJVLQUHVSHFWRIDQ\FRPPHQWVPDGHZULWWHQRURUDOFRQFHUQLQJ
DQ)63RULWVVWDIIGXULQJWKHFRXUVHRIDQ)26DGMXGLFDWHGGLVSXWH
7KHUH DUH VRPH QRWDEOH FRPPHUFLDO LQVXUDQFH SURGXFW W\SHV WKDW IDOO
RXWVLGHWKHMXULVGLFWLRQRIWKH)267KHVHDUH
&RQWUDFWRUV$OO5LVNV
)LGHOLW\*XDUDQWHH
/HJDO/LDELOLW\LQFOXGLQJ3XEOLF/LDELOLW\DQG3URGXFWVOLDELOLW\
/RVVRISUR¿WV%XVLQHVV,QWHUUXSWLRQ
3URIHVVLRQDO,QGHPQLW\DQG
,QGXVWULDO6SHFLDO5LVNV
6FKHGXOH RI WKH 725 RXWOLQHV WKH MXULVGLFWLRQDO OLPLWV WR ZKLFK DQ )26
,ELG3DUD
16
,ELG3DUD
,ELG3DUDVDQG
,ELG6HFWLRQ*,QWHUSUHWDWLRQRI'H¿QHG7HUPV±3DUD
UHPHG\LVVXEMHFWWR,WFRQVWLWXWHVWKHPD[LPXPDZDUGWKDWFDQEHPDGH
E\)26LQUHVSHFWRIDGLVSXWH
7KHWDEOHEHORZVSHFL¿HVDFFRUGLQJWRW\SHRIFODLPWKHPD[LPXPWRWDOYDOXH
RIWKHUHPHG\WKDWPD\EHGHFLGHGXSRQE\)26H[FOXGLQJFRPSHQVDWLRQ
IRUFRVWVDQGLQWHUHVWSD\PHQWV
7\SHRI&ODLP
$PRXQWSHU&ODLP
&ODLP RQ D /LIH ,QVXUDQFH 3ROLF\ RU D *HQHUDO SHUPRQWK
,QVXUDQFH3ROLF\GHDOLQJZLWKLQFRPHVWUHDPULVN
RUDGYLFHDERXWVXFKDFRQWUDFW
,IWKHFODLPLVLQH[FHVVRIWKLVPRQWKO\OLPLWWKH
PRQWKO\OLPLWZLOODSSO\XQOHVV
% WKHWRWDODPRXQWSD\DEOHXQGHUWKHSROLF\FDQ
EH FDOFXODWHG ZLWK FHUWDLQW\ E\ UHIHUHQFH WR
WKH H[SLU\ GDWH RI WKH SROLF\ DQG RU DJH RI
WKHLQVXUHGDQG
% that total amount is less than the amount
VSHFL¿HGLQURZ
,IWKLVLVWKHFDVHWKHQWKHOLPLWZLOOEHWKHDPRXQW
LQURZ
7KLUG SDUW\ FODLP RQ D *HQHUDO ,QVXUDQFH 3ROLF\
SURYLGLQJ FRYHU LQ UHVSHFW RI SURSHUW\ ORVV RU
GDPDJHFDXVHGE\RUUHVXOWLQJIURPLPSDFWRID
motor vehicle
&ODLPDJDLQVWD*HQHUDO,QVXUDQFH%URNHUH[FHSW
ZKHUH WKH FODLP VROHO\ FRQFHUQV LWV FRQGXFW LQ
UHODWLRQWRD/LIH,QVXUDQFH3ROLF\LQZKLFKFDVH
URZRUDSSOLHVZKLFKHYHULVDSSOLFDEOH
2WKHU
7KH )26 DOVR UHWDLQV WKH FDSDFLW\ WR DGMXGLFDWH GLVSXWHV LQ ZKLFK )UDXG
LVDOOHJHGE\DQLQVXUHU,QVXFKFDVHVPDWWHUVDUHKHDUGE\DVSHFLDOLVW
2PEXGVPDQZKRLQPDQ\FDVHVFRQGXFWVDQLQWHUYLHZZLWKWKH$SSOLFDQW
DQGWKH)637KH2PEXGVPDQFDQGHFOLQHWRKHDUDIUDXGGLVSXWHLQFDVHV
LQZKLFKKHFRQVLGHUVWKDWKHGRHVQRWKDYHWKHFDSDFLW\WRFDOOZLWQHVVHV
DQGWHVWHYLGHQFH±LQRWKHUZRUGV±WRWHVWWKHYHUDFLW\RIWKHHYLGHQFH
DQGDOOHJDWLRQV
,ELG6FKHGXOH
&KULVWRSKHU5RGG
,QDGGLWLRQWRLWVIXQFWLRQWRDGMXGLFDWHGLVSXWHV)26LVDOVRYHVWHGZLWK
DQDXWKRULW\XQGHULWV725WRSURYLGHUHSRUWVDQGUHFRPPHQGDWLRQVWR
JRYHUQPHQW UHJXODWRU\ DXWKRULWLHV VXFK DV WKH $XVWUDOLDQ 6HFXULWLHV DQG
,QYHVWPHQWV&RPPLVVLRQ$6,&WKH3ULYDF\&RPPLVVLRQHUDQGDUHJXODWHG
VHFXULWLHV H[FKDQJH ,W DOVR PXVW FROOHFW DQG UHFRUG FRPSUHKHQVLYH
LQIRUPDWLRQ SHUWDLQLQJ WR LWV GLVSXWH UHVROXWLRQ IXQFWLRQ DQG SXEOLVK WKH
UHOHYDQW GDWD20 )XUWKHUPRUH LW LV DOVR UHVSRQVLEOH IRU PRQLWRULQJ DQG
UHSRUWLQJ V\VWHPLF LVVXHV RQ WKH SDUW RI )63V LQFOXGLQJ LVVXHV LQYROYLQJ
VHULRXVPLVFRQGXFW
D$V\VWHPLFLVVXHLVDQLVVXHWKDWZLOOKDYHDQHIIHFWRQRWKHUSHUVRQVRI
WKHNLQGOLVWHGLQSDUDJUDSKRIWKHVH7HUPVRI5HIHUHQFHEH\RQGWKH
SDUWLHVWRWKH'LVSXWH
E)26 PXVW LGHQWLI\ V\VWHPLF LVVXHV DQG UHIHU WKHVH WR WKH UHOHYDQW
)LQDQFLDO6HUYLFHV3URYLGHUIRUUHPHGLDODFWLRQ,QHDFKFDVH)26PXVW
REWDLQDUHSRUWIURPWKH)LQDQFLDO6HUYLFHV3URYLGHUDVWRWKHUHPHGLDO
DFWLRQXQGHUWDNHQDQGFRQWLQXHWRPRQLWRUWKHPDWWHUXQWLODUHVROXWLRQ
KDVEHHQDFKLHYHGWKDWLVDFFHSWDEOHWR)26
F )26 PXVW UHSRUW V\VWHPLF LVVXHV WR $6,& LQ DFFRUGDQFH ZLWK LWV
REOLJDWLRQVXQGHU$6,&5HJXODWRU\*XLGH
6HULRXVPLVFRQGXFW
)26PXVWDOVRUHSRUWDOOVHULRXVPLVFRQGXFWWR$6,&6HULRXVPLVFRQGXFWLV
FRQGXFWZKLFKPD\EHIUDXGXOHQWJURVVO\QHJOLJHQWRULQYROYHZLOIXOEUHDFKHV
RIDSSOLFDEOHODZVRUREOLJDWLRQVXQGHUWKHVH7HUPVRI5HIHUHQFH21
7KHVH IXQFWLRQV DUH SHUIRUPHG LQ FRQMXQFWLRQ ZLWK WKH FXUUHQW )26
UHVSRQVLELOLW\WRPRQLWRULQGXVWU\DGKHUHQFHWRWKH*HQHUDO,QVXUDQFH&RGH
RI 3UDFWLFH 7KLV LV D YROXQWDU\ FRGH HQWHUHG LQWR E\ $XVWUDOLDQ *HQHUDO
,QVXUHUVLQ22WKHSXUSRVHRIZKLFKLVWRHQVXUHFRPPLWPHQWRQWKH
SDUW RI VLJQDWRULHV WR³WR UDLVLQJ VWDQGDUGV RI VHUYLFH WR RXU FXVWRPHUV
7KLVYROXQWDU\&RGHVHWVRXWWKHPLQLPXPVWDQGDUGVZHZLOOXSKROGLQWKH
VHUYLFHVZHSURYLGH\RX´
7KH&RGHHQFRPSDVVHV
%X\LQJ,QVXUDQFH
,QVXUDQFH&ODLPV
5HVSRQGLQJWRFDWDVWURSKHVDQGGLVDVWHUV
,QIRUPDWLRQDQGHGXFDWLRQ
20
2S&LW)267253DUDVDQG
21
,ELG3DUDVDQG
22
*HQHUDO,QVXUDQFH&RGHRI3UDFWLFH3DUD
&RPSODLQWVKDQGOLQJSURFHGXUHV
&RGHPRQLWRULQJDQGHQIRUFHPHQW
7KH)26DGMXGLFDWLRQVFKHPHDVWKH*HQHUDO,QVXUDQFHH[WHUQDOGLVSXWH
UHVROXWLRQPHFKDQLVPLVVLPSO\RQHSDUWRIWKH$'5SURFHVV$QLQWHJUDO
SDUWRI$'5LVWKHLQVXUHU¶VLQWHUQDOPHFKDQLVPZKLFKRSHUDWHVLQFRQFHUW
ZLWKWKH)267KH,QWHUQDO'LVSXWH5HVROXWLRQ,'5IXQFWLRQSHUIRUPHGE\
LQVXUHUVHQVXUHVWKHVXFFHVVRI('5,IQRWIRUDQHI¿FLHQWLQGHSHQGHQW
,'5LWZRXOGEHGLI¿FXOWIRUWKH)26WRIXQFWLRQ$EVHQW,'5)26ZRXOG
EHRYHUZKHOPHGE\GLVSXWHV
%\ZD\RIH[DPSOHWKH%ULVEDQHÀRRGVRIUHVXOWHGLQWKRXVDQGVRI
FODLPVPDQ\RIZKLFKZHUHH[FOXGHGEHFDXVHWKHPDMRULW\RILQVXUDQFH
SROLFLHV LQ WKH PDUNHW DW WKH WLPH GLG QRW FRYHU ORVVHV FDXVHG E\ ÀRRG
FRYHU IRU VWRUP ZDWHU GDPDJH RQO\ )ROORZLQJ WKH GHFLVLRQV RI WKH
FRPSDQLHV¶,'5GHSDUWPHQWVWRUHMHFWWKHFODLPVRQWKHEDVLVRIWKHÀRRG
H[FOXVLRQWKH)26UHFHLYHGKXQGUHGVRIFODLPVGLVSXWHV)RUWXQDWHO\WKH
VLWXDWLRQLVXQOLNHO\WRRFFXUQRZGXHWRWKHZLGHVSUHDGDYDLODELOLW\RIÀRRG
FRYHUXQGHUGRPHVWLFLQVXUDQFHFRQWUDFWV+RZHYHUIRU\HDUV)26IDFHG
VLJQL¿FDQWORJLVWLFDOFKDOOHQJHVGHDOLQJZLWKWKHYROXPHRIFODLPVGLVSXWHV
DULVLQJIURPWKHVWRUPHYHQWV
,QWKLVUHJDUG,'5DFWVDVD¿OWHUIRU)26DQGSURYLGHVWKHLQVXUHUZLWKDQ
RSSRUWXQLW\WRUHVROYHGLVSXWHVEHIRUHWKH\DUHHVFDODWHGWR('5)26
7KDW VDLG PDQ\ LQVXUHGV DZDUH RI WKH H[LVWHQFH RI )26 FRQWDFW )26
LQLWLDOO\ EHIRUH DFFHVVLQJ ,'5 DQG LQ PDQ\ LQVWDQFHV RQO\ FRPH WR ,'5
ZKHQDGYLVHGWRGRVRE\)26RQWKHEDVLVWKDW)26GRQRWVHHNWRIRUPDOO\
LQWHUYHQHLQWKHGHFLVLRQPDNLQJSURFHVVXQWLOWKH)63KDVJLYHQLWV¿QDO
,'5GHFLVLRQ
7KHDGYDQWDJHRI,'5LQYROYHPHQWSURYLGHGLWLVREMHFWLYHLVWKDWLWDIIRUGV
WKH )63 DQ RSSRUWXQLW\ WR UHVROYH GLVSXWHV EHIRUH LQFXUULQJ ZKDW FDQ
DPRXQWWRVXEVWDQWLDO)26IHHVDQGFKDUJHV+RZHYHUIURPWKHDXWKRU¶V
H[SHULHQFHLQVXUHGVFODLPDQWVDUHRIWHQGLVLQFOLQHGWRDFFHSWDQ,'5
GHFLVLRQXQOHVVLWLVZKROO\RUODUJHO\LQWKHLUIDYRXUDZDUHRIWKHIDFWWKDW
WKH\ KDYH D ULJKW WR DFFHVV ZLWKRXW FKDUJH WKH H[WHUQDO LQGHSHQGHQW
VFKHPH)RUREYLRXVUHDVRQVLQVXFKFDVHVLWLVOHVVOLNHO\WKDWDGLVSXWH
ZLOOEHUHVROYHGLIWKH,'5GHFLVLRQLVXQIDYRXUDEOHWRDQDSSOLFDQW
8QIRUWXQDWHO\ WKHUH LV QR SXEOLVKHG RU DFFHVVLEOH GDWD DV WR LQGXVWU\
H[SHULHQFHLQWKHUHVROXWLRQRIGLVSXWHVZLWKRXW)26LQYROYHPHQW+RZHYHU
WKH DXWKRU KDV WKH H[SHULHQFH RI KLV RZQ RUJDQLVDWLRQ ZKLFK LQGLFDWHV
WKHIROORZLQJ&XUUHQWO\LQWKHDXWKRU¶VHPSOR\HU¶V,'5GHSDUWPHQW
7KHDXWKRUKHDGHGXSWKH,'5'HSDUWPHQWRIDODUJHJHQHUDOLQVXUHUIRURYHU\HDUV
&KULVWRSKHU5RGG
KDV UHVROYHG DSSUR[LPDWHO\ RI DOO ,'5 GLVSXWH UHIHUUDOV ZLWKRXW
)26LQYROYHPHQWE\ZD\RIUHFRPPHQGDWLRQGHWHUPLQDWLRQFRQFLOLDWLRQ
RUPHGLDWLRQDOWKRXJKPDQ\RIWKHVHFDVHVKDGDOUHDG\EHHQUHJLVWHUHG
ZLWK)26,QSULRU\HDUVIRUWKH¿JXUHZDVRXWRIDWRWDO
RIUHFRUGHGGLVSXWHVRIZDVRXWRIDWRWDORIGLVSXWHV
RIZDVRXWRIDWRWDORIDQGRXWRI
DWRWDORIGLVSXWHV$FFRUGLQJO\,'5FDQDQGGRHVIXO¿ODXVHIXODQG
HIIHFWLYHIXQFWLRQLQWKHUHVROXWLRQRIGLVSXWHV
7KH SXEOLVKHG GDWD SURYLGHG E\ WKH )26 DSSHDUV LQ LWV DQQXDO UHSRUW24
7KH UHSRUW LQFOXGHV LQIRUPDWLRQ FRQFHUQLQJ PDWWHUV UHVROYHG
E\DJUHHPHQWZLWKWKH¿QDQFLDOVHUYLFHSURYLGHU)63
GLVSXWHV ZHUH UHIHUUHG WR )26 GXULQJ WKH UHOHYDQW \HDU 2I WKDW
QXPEHUZHUHUHVROYHGE\DJUHHPHQWEHWZHHQWKH$SSOLFDQW
DQGWKH)63ZLWKE\QHJRWLDWLRQE\DVVHVVPHQW
DQGE\FRQFLOLDWLRQ
2QFH)26EHFRPHVLQYROYHGPDQ\JHQHUDOLQVXUHUVVHHNWRWU\DQGUHVROYH
D GLVSXWH E\ QHJRWLDWLRQ DOWKRXJK WKH H[SHULHQFH LV VXEMHFW WR ZLGH
ÀXFWXDWLRQV,QWKHFDVHRIRQHLQVXUHUUHVROXWLRQE\QHJRWLDWLRQZDVDV
KLJKDVDQGIRUDQRWKHUDVORZDV,QWKHFDVHRIWKHIRUPHUIRU
WKRVH GLVSXWHV WKDW XOWLPDWHO\ SURFHHGHG WR D 'HWHUPLQDWLRQ ZHUH LQ
WKHDSSOLFDQW¶VIDYRXUZKLOHZHUHLQIDYRXURIWKH)63&RQWUDVWLQJWKH
IRUPHUZLWKWKHODWWHUZKHUHZHUHLQIDYRXURIWKHDSSOLFDQWDQGRQO\
LQIDYRXURIWKH)63267KLVVXJJHVWVRQHRIWZRWKLQJV)26ORRNVPRUH
IDYRXUDEO\XSRQ)63VWKDWVHHNWRQHJRWLDWHWKDQWKRVHWKDWGRQ¶WRUWKH
)63PDGHDSRRUMXGJHPHQWFDOOZKHQWKHLQLWLDOGHFLVLRQZDVPDGH
,Q WKH H[DPSOH RI PRWRU YHKLFOH LQVXUDQFH GLVSXWHV WKH ¿JXUHV IRU
QHJRWLDWHG UHVROXWLRQ DUH HYHQ PRUH VWDUN ,Q WKH FDVH RI RQH LQVXUHU
RI PRWRU YHKLFOH GLVSXWHV ZHUH UHVROYHG E\ QHJRWLDWLRQ ZLWK WKH
ORZHVWSHUFHQWDJHE\DQ\LQVXUHUDW,QWKHFDVHRIWKHODWWHU
UHVXOWHGLQDGHWHUPLQDWLRQLQIDYRXURIWKHDSSOLFDQWDQGLQIDYRXU
RIWKH)63
8QIRUWXQDWHO\ZKLOHWKH¿JXUHVXJJHVWVDYHU\KLJKUHVROXWLRQUDWHZLWK
)26SDUWLFLSDWLRQLWSURYLGHVQRLQVLJKWDVWRLQGXVWU\RXWFRPHVDEVHQWDQ\
)26LQYROYHPHQWZKHWKHUWKDWLQYROYHPHQWPHDQWVLPSOH)26UHJLVWUDWLRQ
RUGLUHFWSDUWLFLSDWLRQ
24
)LQDQFLDO2PEXGVPDQV6HUYLFH$QQXDO5HYLHZDQQXDOUHSRUW
,ELGDWSDJH
26
)26,QGXVWU\&RPSDUDWLYH7DEOHV±+RPH%XLOGLQJV
,ELG±0RWRU9HKLFOH
Critique of FOS System
7KH VWDWHG REMHFWLYH RI WKH )26 VFKHPH LV WR ³UHVROYH GLVSXWHV LQ D
FRRSHUDWLYHHI¿FLHQWWLPHO\DQGIDLUPDQQHUZLWKWKHPLQLPXPIRUPDOLW\
DQGWHFKQLFDOLW\´
)URP WKH VWDQGSRLQW RI WKH FRQVXPHU LW ZRXOG DSSHDU WKDW WKH VFKHPH
DFKLHYHV WKRVH REMHFWLYHV EXW WKDW PD\ QRW EH WKH VKDUHG YLHZ RI WKH
LQGXVWU\ 7KH )26 VFKHPH LV UHODWLYHO\ H[SHQVLYH DQG FOHDUO\ ZKLOH
FKHDSHUWKDQOLWLJDWLRQIRUERWKSDUWLHVWKHUHDOLW\LVWKDWIHZFRQVXPHUV
FRXOG DIIRUG WR LQVWLWXWH OLWLJDWLRQ RU JHQXLQHO\ DUH FRPPLWWHG HQRXJK WR
WKHPHULWVRIWKHLUFDXVHWRSXUVXHOLWLJDWLRQ
$V SUHYLRXVO\ PHQWLRQHG )26 LV IXQGHG HQWLUHO\ E\ WKH )63V ZLWK
QR ¿QDQFLDO FRPPLWPHQW UHTXLUHG IURP WKH FRQVXPHUDSSOLFDQW 7KH
SURPRWLRQDO PDWHULDO RQ WKH )26 ZHEVLWH WHQGV WR HQFRXUDJH HDV\
ORGJHPHQWRIDGLVSXWHVXSSRUWHGE\DWHDPRIFRQVXPHUDGYLVHUVZLWKLQ
WKHRUJDQLVDWLRQ
2QFHDGLVSXWHKDVEHHQUHJLVWHUHGZLWK)26WKHFRVWVIRUWKH)63EHJLQWR
UXQDQGDFFRUGLQJO\DVIHHVDUHFKDUJHGRQD³IHHIRUVHUYLFHÉDVLVWKH
ORQJHUWKHPDWWHUSURJUHVVHVWKHJUHDWHUWKHFRVWWRWKH)63$FFRUGLQJO\
IRUGLVSXWHVLQYROYLQJVPDOOHUPRQHWDU\DPRXQWVVXFKDVSD\PHQWRIDQ
H[FHVVRQFH)26LVLQYROYHGLWLVPRUHFRVWHIIHFWLYHWRHLWKHUZDLYHRUWR
SD\WKHGLVSXWHGVXPUDWKHUWKDQLQFXU)26IHHV
7KH)26SURPRWHVWKHIDFWWKDWLWV³PHPEHUVKLSEDVHRIPHPEHUV
KDVFKRVHQXVDVWKHLUH[WHUQDOGLVSXWHUHVROXWLRQVFKHPH´,QWKHFDVHRI
WKHJHQHUDOLQVXUHUVWKDWLVQ¶WVWULFWO\VSHDNLQJFRUUHFW7KHUHLVQRRWKHU
('5VFKHPHIRUJHQHUDOLQVXUDQFHGLVSXWHVFXUUHQWO\DYDLODEOHLQ$XVWUDOLD
DQG DV SDUWLFLSDWLRQ LQ DQ $6,& DSSURYHG ('5 VFKHPH LV D FRQGLWLRQ RI
WKHLVVXDQFHRIDQLQVXUHU¶VOLFHQFHLQVXUHUVKDYHQRFKRLFHRWKHUWKDQWR
VLJQXSWRWKH)26$FFRUGLQJO\LWLVDUJXDEO\PLVOHDGLQJWRGHVFULEHWKH
JHQHUDOLQVXUHUV¶SDUWLFLSDWLRQDVHQWLUHO\YROXQWDU\
,QGXVWU\FRQFHUQDVWR)26SRZHUVIRFXVRQDQXPEHURINH\DUHDVQDPHO\
$EVHQFHRIDQ\JHQXLQHULJKWRIUHYLHZRUDSSHDOSURFHVV
$EVHQFHRIDGKHUHQFHWRSUHFHGHQWLQWKH)26DSSURDFKWRGHFLVLRQ
PDNLQJ
7KH IDFW WKDW E\ LWV 725 )26 LV QRW ERXQG E\ DQ\ UXOHV RI ODZ RU
HYLGHQFHLQPDNLQJLWVGHWHUPLQDWLRQV
2S&LW±)26$QQXDO5HYLHZDWSDJH
$OOKROGHUVRIDQ$XVWUDOLDQ)LQDQFLDO6HUYLFHV/LFHQVH$)6/PXVWKROGPHPEHUVKLSRIDQ
DSSURYHG('5VFKHPH7KHUHLVFXUUHQWO\DQRWKHUVFKHPHDYDLODEOHIRU¿QDQFLDOVHUYLFH
SURYLGHUVLQ$XVWUDOLDEXWLWLVQ¶WUHVRXUFHGWRKDQGOHJHQHUDOLQVXUDQFHGLVSXWHV±&26/
&KULVWRSKHU5RGG
7KDW LQ $XVWUDOLD )26 LQYROYHPHQW LQ VR PDQ\ LQVXUDQFH UHODWHG
GLVSXWHVHIIHFWLYHO\PHDQVWKDWZHDUHVHHLQJYHU\OLWWOHHYROXWLRQLQ
LQVXUDQFHODZRXWVLGHOLDELOLW\ZRUNHUVFRPSHQVDWLRQPRWRUYHKLFOH
SHUVRQDOLQMXU\DQGSURIHVVLRQDOLQGHPQLW\
3HUFHLYHGELDVLQÀXHQFHGE\WKHSURFRQVXPHUQDWXUHRIWKH725
,QUHODWLRQWRWKH¿UVWLVVXHWKHJHQHUDOLQVXUDQFHLQGXVWU\VSHFL¿FDOO\KDV
YRLFHGFRQFHUQWKDWWKHUHUHPDLQVQRVDWLVIDFWRU\PHFKDQLVPWRUHYLHZDQ
)26 GHWHUPLQDWLRQ WKDW RQ LWV IDFH KDV DSSOLHG WKH ODZ LQFRUUHFWO\ RU LQ
ZKLFK)26KDVH[FHHGHGLWVMXULVGLFWLRQ¿QDQFLDORURWKHUZLVHRULQZKLFK
WKH GHFLVLRQ KDV SURGXFHG DQ RXWFRPH WR WKH )63¶V GHWULPHQW LQ HLWKHU
PLVFRQVWUXLQJWKHODZRUVLPSO\DSSO\LQJLWLQFRUUHFWO\
5HFHQWO\ WKH )26 DSSURDFKHG WKH LQGXVWU\ VXJJHVWLQJ D PHFKDQLVP IRU
UHYLHZLQJ )26 GHWHUPLQDWLRQV ZKHUH WKH )63 DVVHUWHG WKDW WKH GHFLVLRQ
ZDV HLWKHU LQFRUUHFW DW ODZ RU LQ H[FHVV RI MXULVGLFWLRQ )26 SURSRVHG
D PHFKDQLVP ZKLFK UHTXLUHG )26 FRQVHQW WR SXUVXH WKH UHYLHZ ZKLFK
)26ZDVQRWERXQGWRFRQVHQWWRIXOO\IXQGHGDWHYHU\VWDJHE\WKH)63
QRW)26ZKLFKSRWHQWLDOO\FRXOGUHVXOWLQDGHFLVLRQZKLFK)26ZDVQRW
ERXQGWRDGKHUHWRDQGZKLFKZRXOGQRWUHVXOWLQDUHYHUVDORIWKHLQLWLDO
GHFLVLRQ7KHLQGXVWU\GLGQRWVXSSRUWWKHSURSRVDODQGWKHLVVXHUHODWLQJ
WRDQDSSURSULDWH³UHYLHZPHFKDQLVPÚHPDLQVXQUHVROYHG
7KH $XVWUDOLDQ &RXUWV KDYH FRQVLGHUHG WKH LVVXH RI MXGLFLDO UHYLHZ RI
YROXQWDU\WULEXQDOGHFLVLRQVLQDQXPEHURIFDVHVRYHUWKHODVW\HDUV
7ZRDUHQRWDEOH
,Q WKH FDVH RI 8WRSLD )LQDQFLDO 6HUYLFHV 3W\ /WG Y )LQDQFLDO 2PEXGVPDQ
6HUYLFH /WG -XVWLFH / 0LHUH FRPPHQWHG WKDW WKH )26 GLVFUHWLRQ LQ
GHFLGLQJ D UHPHG\ LV YHU\ ZLGH DQG RQ WKH IDFWV RI WKH FDVH ZDV QRW
DPHQDEOHWRMXGLFLDOUHYLHZ+LVGHFLVLRQZDVEDVHGRQWKHIDFWWKDWWKH
725HQDEOHG)26WRGRZKDWLQLWVRSLQLRQLVIDLUDQGUHDVRQDEOHLQDOOWKH
FLUFXPVWDQFHV7KHDUJXPHQWEHLQJWKDWLIDQRUJDQLVDWLRQYROXQWDULO\VLJQV
XSWRDWULEXQDOVFKHPHWKDWKDVUXOHVWKDWSUHFOXGHDQ\ULJKWRIMXGLFLDO
DSSHDOWKDWRUJDQLVDWLRQHIIHFWLYHO\VLJQVDZD\E\FRQWUDFWRUDJUHHPHQW
WKH ULJKW WR UHTXHVW MXGLFLDO UHYLHZ $ IXUWKHU FDVH WKDW FRQVLGHUHG WKLV
LVVXHZDV0LFNRYVNLY)LQDQFLDO2PEXGVPDQ6HUYLFH/LPLWHGDQG$QRU
,QWKDWFDVHWKH9LFWRULDQ&RXUWRI$SSHDOKHOGWKDWWKH)26725GLGQRW
7KHVHDUHDVIDOORXWVLGHWKHMXULVGLFWLRQRI)26
>@:$6&
>@96&$&RQWUDVWWKLVGHFLVLRQZLWKWKDWRIWKH16:6XSUHPH&RXUWGHFLVLRQ
in 0DVX)LQDQFLDO0DQDJHPHQW3W\/WGY)LQDQFLDO,QGXVWU\&RPSODLQWV6HUYLFHV/WGQRV
DQG$&657KHGHFLVLRQVDSSHDURQWKHLUIDFHWREHLUUHFRQFLODEOH
>@96&$
JLYHULVHWRMXGLFLDOUHYLHZLQFDVHVVXFKDV)26DSSO\LQJWKHODZLQFRUUHFWO\
EXWGLGFRPPHQWWKDWLQWKHHYHQWWKDWDWULEXQDOEUHDFKHGLWVFRQWUDFWXDO
DJUHHPHQW ZLWK RQH RI LWV PHPEHU RUJDQLVDWLRQV VXFK DV PLJKW RFFXU LI
WKH WULEXQDO H[FHHGHG LWV MXULVGLFWLRQ WKHQ LQ VR GRLQJ LW PD\ EUHDFK LWV
FRQWUDFW LQ ZKLFK FDVH D MXGLFLDO UHYLHZ PD\ EH RSHQ WR WKH DJJULHYHG
SDUW\7KHFRXUWREVHUYHGLQMickovski:
³6LQFHWKH$FWDVEHIRUHWKHSXEOLFGRQRWKDYHWRXVHWKH>)26@7KH\FDQ
LQVWHDGVXHLQVXUHUVLQWKHFRXUWV,IWKH\JREHIRUHWKH>)26@EHFDXVH>LW@
LVQRWOLPLWHGWRSXUHO\OHJDOFRQVLGHUDWLRQVLQPDQ\FDVHVWKHLUSURVSHFWV
RIVXFFHVVZLOOEHEHWWHU%XWWKH\KDYHWKHFKRLFHRIIRUXP7KH>)26¶V@
SRZHU RYHU LWV PHPEHUV LV VWLOO GHVSLWH WKH $FW VROHO\ GHULYHG IURP
FRQWUDFW DQG LW VLPSO\ FDQQRW EH VDLG WKDW LW H[HUFLVHV JRYHUQPHQWDO
IXQFWLRQV,QDQXWVKHOOHYHQLILWFDQEHVDLGWKDWLWKDVQRZEHHQZRYHQ
LQWRDJRYHUQPHQWDOV\VWHPWKHVRXUFHRILWVSRZHULVVWLOOFRQWUDFWXDOLWV
GHFLVLRQVDUHRIDQDUELWUDWLYHQDWXUHLQSULYDWHODZDQGWKRVHGHFLVLRQVDUH
QRWVDYHYHU\UHPRWHO\VXSSRUWHGE\DQ\SXEOLFODZVDQFWLRQ,QWKHOLJKW
RIWKHVHIDFWRUVWKH>)26@LVQRWLQP\MXGJHPHQWDERG\VXVFHSWLEOHWR
MXGLFLDOUHYLHZ´
$FFRUGLQJO\ EDVHG RQ WKH IDFW WKDW WKHUH ZDV QR DSSDUHQW FRQWUDFWXDO
EUHDFKWKH&RXUWIRXQGWKDWWKHUHZDVQRULJKWRIDSSHDO
+RZHYHU WKHUH PD\ EH FLUFXPVWDQFHV WKDW PD\ JLYH ULVH WR D ULJKW RI
DSSHDOZKHUHWKHUHKDVEHHQDEUHDFKRIFRQWUDFWEHWZHHQWKH)63DQG
)267KLVPLJKWRFFXUE\ZD\RILOOXVWUDWLRQLI)26H[FHHGHGLWV¿QDQFLDO
OLPLWRUPDGHDGHWHUPLQDWLRQWKDWLQYROYHGDFODVVRILQVXUDQFHRXWVLGH
LWV 725 7R GDWH WKH ZULWHU LV XQDZDUH RI DQ\ LQVWDQFH LQ ZKLFK D OHJDO
FKDOOHQJHRQWKHJURXQGVRXWOLQHGKDVEHHQLVVXHG
7KHFRQFHSWRIUHYLHZLQJWKHGHFLVLRQVRITXDVLMXGLFLDOERGLHVUHPDLQVD
YH[HGLVVXHDQGQRWDEO\ZDVDWRSLFUDLVHGE\+LV+RQRXU-XVWLFH6SLJHOPDQ
WKH WKHQ &KLHI -XVWLFH RI WKH 16: 6XSUHPH &RXUW DW WKH th :RUOGZLGH
&RPPRQ /DZ -XGLFLDO &RQIHUHQFH LQ /RQGRQ LQ ZKHQ +LV +RQRXU
REVHUYHG
³LWLVSRVVLEOHWKDWWKHFRQWLQXHGH[SDQVLRQLQWKHXVHRIQRQMXGLFLDO
GHFLVLRQPDNLQJSURFHVVHVWRUHVROYHGLVSXWHVDQGWRGHWHUPLQHULJKWVFDQ
EHFRPH VR VLJQL¿FDQW DV WR GHSULYH WKH LGHD RI MXGLFLDO LQGHSHQGHQFH RI
D JUHDW GHDO RI LWV SUDFWLFDO FRQWHQW :H PD\ QRW KDYH JLYHQ VXI¿FLHQW
DWWHQWLRQWRWKLVDVSHFWRILQGHSHQGHQFH7KLVLVDPDWWHUWKDWFDQRQO\
EHDVVHVVHGLQWKHFRQWH[WRIDVSHFL¿FMXULVGLFWLRQWRDQRWKHU2QHFDQQRW
GHWHUPLQHDQ\FOHDUOLQHEHWZHHQZKDWPXVWEHMXGLFLDOGHFLVLRQPDNLQJ
DQG ZKDW PD\ SURSHUO\ EH UHJDUGHG DV DGPLQLVWUDWLYH RU TXDVLMXGLFLDO
,ELGSHU-XVWLFHDWSDJH
&KULVWRSKHU5RGG
GHFLVLRQ PDNLQJ 1HYHUWKHOHVV WKH H[WHQW WR ZKLFK PDWWHUV FDSDEOH RI
MXGLFLDOGHWHUPLQDWLRQDUHLQIDFWUHPRYHGWRWULEXQDOVRIWHQFDOOHGFRXUWV
ZKLFKGRQRWKDYHWKHEHQH¿WRIWKHPLQLPXPUHTXLUHPHQWVRIWUDGLWLRQDO
VHFWLRQVRIWKHLQGHSHQGHQFHRIWKHMXGLFLDU\WKHQWKHUHPD\EHFDXVHIRU
FRQFHUQ´
7KHUH UHPDLQV D JHQHUDO FRQVHQVXV LQ WKH LQGXVWU\ WKDW LQ OLPLWHG
FLUFXPVWDQFHVWKHULJKWWRMXGLFLDOUHYLHZRI)26GHFLVLRQVVKRXOGEHDQ
RSWLRQDYDLODEOHWRLW
$QRWKHULVVXHRIFRQFHUQWRLQGXVWU\PHPEHUVUHODWHVWRDEVHQFHRI)26
DGKHUHQFHWRSUHFHGHQW7KLVLVYLHZHGLQWKHFRQWH[WWR)26µVRZQSULRU
GHFLVLRQV7KH725GRHVQRWELQG)26WRLWVRZQHDUOLHUGHFLVLRQVZKLFKLQ
WXUQFUHDWHVSRWHQWLDOSUREOHPVIRUDQLQGXVWU\WKDWHQGHDYRXUVWRWUDLQLWV
VWDIIEDVHGRQ)26GHFLVLRQV2EYLRXVO\LIVLPLODUIDFWVDQGFLUFXPVWDQFHV
FUHDWH)26RXWFRPHVDSSDUHQWO\DWRGGVZLWKRQHDQRWKHULWPDNHVLWGLI¿FXOW
WRWUDLQVWDIIZKLFKLQWXUQFUHDWHVWKHSRWHQWLDOIRUDODFNRIFRQ¿GHQFHLQ
WKH)26GHFLVLRQPDNLQJSURFHVV:KLOH)26XQGHUVWDQGDEO\DVVHUWVWKDW
FRQVLVWHQF\LVLPSRUWDQWLQHQVXULQJFRQ¿GHQFHLQWKHSURIHVVLRQDOLVPDQG
LQGHSHQGHQFH RI WKH SURFHVV LQFRQVLVWHQW DQG VHHPLQJO\ LUUHFRQFLODEOH
GHFLVLRQVEHOLHVWKDWREMHFWLYH+RZHYHU)26GRHVHQGHDYRXUWRDGHJUHH
WRDGKHUHWRFRQVLVWHQF\RIGHFLVLRQPDNLQJ,WLVHQWLUHO\XQGHUVWDQGDEOH
WKDWDSURFHVVVXFKDVWKH)26VFKHPHVKRXOGQRWEHHQWLUHO\FRQVWUDLQHG
E\ DGKHUHQFH WR LWV RZQ SUHFHGHQW EXW WKDW VDLG IURP DQ LQGXVWU\
SHUVSHFWLYH WKHUH LV D YLHZ WKDW VLPLODU IDFWV DQG FLUFXPVWDQFHV VKRXOG
SURYLGHDVLPLODURXWFRPH
,VVXHUHODWHVWRWKHDSSOLFDWLRQRIWKHODZDQGZKDWLVSHUFHLYHGE\PDQ\
LQWKHLQGXVWU\DVDQLVVXHRI³IDLUQHVV´7KLVZDVDGGUHVVHGLQDUHFHQW
VXEPLVVLRQIURPWKH,QVXUDQFH&RXQFLORI$XVWUDOLDWRWKH&RPSHWLWLRQDQG
&RQVXPHU3ROLF\'LYLVLRQRIWKH)HGHUDO'HSWRI7UHDVXU\7KHVXEPLVVLRQ
DVVHUWHG WKDW WKH FXUUHQW 725 FUHDWHV DPELJXLW\ E\ SODFLQJ XQGXH
HPSKDVLV RQ ³IDLU DQG UHDVRQDEOH´ 7KH VXJJHVWLRQ ZDV PDGH WKDW WKH
WHUP³IDLUQHVV´VKRXOGEHUHZULWWHQDVIROORZV
³ WKDW LQGXVWU\ VFKHPHV SURYLGH WKDW WKH GHFLVLRQPDNHU PDNHV
GHWHUPLQDWLRQVLQDFFRUGDQFHZLWKUHOHYDQWLQGXVWU\FRGHVRISUDFWLFHDQG
WKHODZDQGPD\LQGRLQJVRFRQVLGHUZKDWLVIDLUDQGUHDVRQDEOHKDYLQJ
UHJDUGWRJRRGLQGXVWU\SUDFWLFH´
³-XGLFLDO,QGHSHQGHQFH3XUSRVHVDQG7KUHDWV´´$GGUHVVE\WKH+RQ--6SLJHOPDQ$&
&KLHI -XVWLFH RI 16: ± th :RUOGZLGH &RPPRQ /DZ -XGLFLDO &RQIHUHQFH $SULO /RQGRQ
7KLVUHIHUVWRSDUDRIWKH)267HUPVRI5HIHUHQFH
/HWWHUIURPWKH,&$WR&&$$&6HFUHWDULDW&RQVXPHU3ROLF\)UDPHZRUN8QLW&RPSHWLWLRQ
DQG&RQVXPHU3ROLF\'LYLVLRQ)HGHUDO7UHDVXU\GDWHG
60
,QHVVHQFHWKHVXEPLVVLRQVXJJHVWVDUHGUDIWRIWKHODQJXDJHXVHGLQWKH
725SDUDWRVWUHVVWKDWIDLUQHVVQHHGVWRRSHUDWHLQWKHFRQWH[WRI
WKHODZDQGLQGXVWU\FRGHVRISUDFWLFHUDWKHUWKDQLQGHSHQGHQWRIDOOWKH
UHOHYDQWFULWHULDRXWOLQHGLQWKHODQJXDJHRI725
,WHPFRQVWLWXWHVWKHDXWKRU¶VYLHZWKDWZKLOHWKH)26VFKHPHRSHUDWHV
HI¿FLHQWO\ DQG HIIHFWLYHO\ DV D ORZ FRVW GLVSXWH UHVROXWLRQ VFKHPH LWV
VXFFHVV KDV FRPH DW D SULFH LQ WHUPV RI LQVXUDQFH ODZ HYROXWLRQ :KHQ
WKH,QVXUDQFH&RQWUDFWV$FWZDVHQDFWHGXQGHUVWDQGDEO\DJUHDW
GHDORIOLWLJDWLRQIROORZHGDVWKHYDULRXVVWDNHKROGHUVVRXJKWWRFODULI\WKH
PHDQLQJDQGSXUSRVHRIWKHOHJLVODWLRQ¶VSURYLVLRQV$VDFRQVHTXHQFHD
YDVW ERG\ RI FDVH ODZ GHYHORSHG IURP RQZDUGV 8QIRUWXQDWHO\ RU
IRUWXQDWHO\GHSHQGLQJXSRQ\RXUSHUVSHFWLYHVLQFHWKHDGYHQWRIWKH)26
DQGLWVSUHGHFHVVRUVFKHPHVWKHQXPEHURIFDVHVGHDOLQJZLWKLQVXUDQFH
ODZ LVVXHV KDV UHGXFHG GUDPDWLFDOO\ :KLOH WKDW LV QRW DQ HQWLUHO\ EDG
RXWFRPHDVDFRQVHTXHQFHIHZFDVHVDUHOLWLJDWHGWKDWKDYHWKHSRWHQWLDO
WR H[SDQG NQRZOHGJH DQG XQGHUVWDQGLQJ RI WKH ODZ %\ ZD\ RI VLPSOH
LOOXVWUDWLRQYHU\IHZFDVHVKDYHDSSHDUHGZLWKLQWKHODVW\HDUVGHDOLQJ
ZLWK
7KHULJKWVRIWKHLQQRFHQWFRLQVXUHGRQLVVXHVRIQRQGLVFORVXUH
7KLUG3DUW\LQWHUHVWVXQGHUDFRQWUDFWRILQVXUDQFH
3URRIRIGLVSDWFKRIGRFXPHQWDWLRQ
5HPHGLHVDYDLODEOHIRUDEUHDFKRIWKH'XW\RI8WPRVW*RRG)DLWK
([SDQVLRQRIWKHODZRQWKHLVVXHRIWKHULJKWVDQGUHPHGLHVUHMRLQW
DQGFRPSRVLWHSROLFLHVRILQVXUDQFH
,QVWDOPHQWFRQWUDFWV
$Q H[DPLQDWLRQ RI WKH $XVWUDOLDQ &&+ ,QVXUDQFH 5HSRUWHU GHDOLQJ ZLWK
GHFLGHGFDVHVXSXQWLOUHYHDOHGWKHIROORZLQJ
±FDVHV
±FDVHV
±FDVHVLQFOXGLQJRQHPDWWHUWKDWZDVUHSRUWHGDW¿UVW
LQVWDQFHDQGRQDSSHDO
$VDFRQVHTXHQFHWKHUHLVGLPLQLVKLQJVFRSHIRUMXGLFLDOO\GHWHUPLQHGODZ
LQPDQ\NH\DUHDVRILQVXUDQFHODZDQGLQSDUWLFXODULQLVVXHVDULVLQJXQGHU
WKH,QVXUDQFH&RQWUDFWV$FW7KLVEHFRPHVDQLVVXHRILQFUHDVLQJ
UHOHYDQFH JLYHQ WKH UHFHQW DPHQGPHQWV WR WKH ,QVXUDQFH &RQWUDFWV $FW
7KHVHQXPEHUVGRQRWUHIHUWRPDWWHUVRXWVLGH)26725VXFKDV&73&RPSXOVRU\7KLUG
3DUW\%RGLO\,QMXU\FODLPV3URIHVVLRQDO,QGHPQLW\/LDELOLW\ZRUNHUVFRPSHQVDWLRQRU,65
,QGXVWULDO6SHFLDO5LVNV
&KULVWRSKHU5RGG
61
HQDFWHGLQ,WLVKRSHGWKDW)26ZLOOUHFRJQLVHWKHQHHGIRU
OHJDOHYROXWLRQWKURXJKMXGLFLDOGHWHUPLQDWLRQDQGGHFOLQHWRKHDUPDWWHUV
UHODWHGWRWKHQHZDPHQGPHQWVXQWLOVXFKWLPHDVWKH&RXUWVKDYHEHHQ
FDOOHGXSRQWRFRQVLGHUWKHSURYLVLRQV
7KH ¿QDO LVVXH UHODWHV WR LQGXVWU\ SHUFHSWLRQV RI ELDV EDVHG RQ WKH
ZRUGLQJ DQG ODQJXDJH XVHG LQ WKH 725 5HFHQW LQGXVWU\ H[SHULHQFH LV
UHQGHULQJWKLVDQLVVXHRIGHFOLQLQJUHOHYDQFHEXWLWH[LVWVQRQHWKHOHVV
)DLUQHVVLQRXWFRPHLVFULWLFDOWRWKHLQGXVWU\¶VUHVSHFWIRUWKHREMHFWLYLW\
RIWKHSURFHVV,ILQGXVWU\SHUFHLYHVELDVWKDWSHUFHSWLRQJHQHUDWHVDODFN
RI FRQ¿GHQFH LQ WKH REMHFWLYLW\ RI WKH DGMXGLFDWRUV DQG WKH DGMXGLFDWLRQ
SURFHVV,QDQDWWHPSWWRDGGUHVVWKHVHFRQFHUQV)26KDVGRQHDORWRI
SRVLWLYHZRUNZLWKLQGXVWU\WKRXJKLQGXVWU\OLDLVRQPHHWLQJVZRUNVKRSV
WUDLQLQJVHPLQDUVWKHDQQXDO)26&RQIHUHQFHDQGVWDIIPHHWLQJV+RZHYHU
LWVHHPVWKDWWKHLQGXVWU\SHUFHSWLRQVDUHXQOLNHO\WRFKDQJHVLJQL¿FDQWO\
XQWLOWKHUHLVDUHGUDIWLQJRIWKH)26725WRGHDOZLWKLVVXHVRIIDLUQHVV
EDODQFLQJLQWHUHVWVULJKWVRIUHYLHZDQDSSHDOPHFKDQLVPGHDGOLQHV
LPSRVHGRQ)63VIRUVXEPLVVLRQVDQGIHHVWUXFWXUHV
Conclusions in Relation to the Financial Ombudsman
Scheme
7KH2PEXGVPDQ6FKHPHIRU*HQHUDO,QVXUDQFHLQRQHIRUPRUDQRWKHU
KDVIXQFWLRQHGHI¿FLHQWO\IRURYHU\HDUVDQGFOHDUO\IURPWKHFRQVXPHU
VWDQGSRLQW KDV SURYLGHG D FRVW IUHH HIIHFWLYH HI¿FLHQW DQG UHODWLYHO\
H[SHGLWLRXVPHFKDQLVPWRFKDOOHQJHWKHGHFLVLRQVRILQVXUHUVDQGEURNHUV
DOLNH,WXQDVKDPHGO\FODLPVWRDVVLVWFRQVXPHUVWRGHDOZLWKWKHP\ULDG
RI LVVXHV WKDW DULVH LQ WKH GHFLVLRQ PDNLQJ SURFHVVHV RI LQVXUDQFH DQG
SURGXFHVRXWFRPHVWKDWZKLOHELQGLQJRQWKH)63DUHQRWELQGLQJRQWKH
FRQVXPHU
:KHWKHU LW VHUYHV WKH LQWHUHVW RI LQVXUHUV LV D PRUH FRQWHQWLRXV LVVXH
$UJXDEO\DSURFHVVIXOO\IXQGHGE\RQO\RQHSDUW\WKDWSURGXFHVRXWFRPHV
ELQGLQJRQRQHSDUW\RQO\IRUZKLFKWKHUHLVQRDYHQXHRIDSSHDOIRURQH
SDUW\GRHVQRWVXJJHVWDEDODQFHGDSSURDFKWR('57KHIDFWWKDW)26LV
QRWUHTXLUHGWRDGKHUHWRUXOHVRIHYLGHQFHODZSUHFHGHQWRULQGHHGJRRG
LQGXVWU\ SUDFWLFH GRHV QRW SRLQW WR D OHYHO SOD\LQJ ¿HOG $OOLHG WR WKHVH
FRQVWUDLQWVLVWKHIXUWKHULPSHGLPHQWWKDWZKLOHDQLQVXUHUPXVWSDUWLFLSDWH
LQDQ('5VFKHPHDVDFRQGLWLRQRILWVLQVXUDQFHOLFHQFHWKHRQO\FXUUHQWO\
DSSURYHG VFKHPH IRU $XVWUDOLD¶V JHQHUDO LQVXUHUV LV )26 7KDW VDLG WKH
FORFNFDQQRWEHZRXQGEDFNVRIRUEHWWHURUZRUVHWKHLQGXVWU\ZLOOQHHG
WR FRQWLQXHWR ZRUN ZLWK )26DQGWKH)HGHUDO 5HJXODWRUVWR HQVXUHWKDW
WKHVFKHPHZRUNVDVIDLUO\DVSRVVLEOHDQGVDWLV¿HVWKHEDODQFLQJRIRIWHQ
FRQÀLFWLQJLQWHUHVWVEHWZHHQFRQVXPHUVDQGWKHLQGXVWU\
62
Litigation, Mediation and Arbitration
)RU PDQ\ \HDUV SULRU WR WKH HQDFWPHQW RI WKH ,QVXUDQFH &RQWUDFWV $FW
PDQ\ $XVWUDOLDQ FRQWUDFWV RI LQVXUDQFH FRQWDLQHG DQ DUELWUDWLRQ
SURYLVLRQZKLFKHQDEOHGLQVXUDQFHGLVSXWHVWREHUHVROYHGE\DUELWUDWLRQ
ZKLFKEDVHGXSRQWKHSURYLVLRQPDGHLWFRPSXOVRU\DWWKHEHKHVWRIWKH
LQVXUHU:KLOHFRVWHIIHFWLYHIRUODUJHFRPPHUFLDOGLVSXWHVLWZDVSRWHQWLDOO\
SURKLELWLYHLQWKHFDVHRIVPDOOHUGRPHVWLFLQVXUDQFHFODLPV
6HFWLRQ RI WKH ,QVXUDQFH &RQWUDFWV $FW HIIHFWLYHO\ UHQGHUHG
FRPSXOVRU\DUELWUDWLRQFODXVHVYRLG6HFWLRQSURYLGHV
:KHUHDSURYLVLRQLQFOXGHGLQDFRQWUDFWRILQVXUDQFHKDVWKHHIIHFW
RI
D5HTXLULQJ DXWKRULVLQJ RU RWKHUZLVH SURYLGLQJ IRU GLIIHUHQFHV
RU GLVSXWHV LQ FRQQHFWLRQ ZLWK WKH FRQWUDFW WR EH UHIHUUHG WR
DUELWUDWLRQRU
E/LPLWLQJ WKH ULJKWV RWKHUZLVH FRQIHUUHG E\ WKH FRQWUDFW RQ WKH
LQVXUHGE\UHIHUHQFHWRDQDJUHHPHQWWRVXEPLWDGLIIHUHQFHRU
GLVSXWHWRDUELWUDWLRQ
7KHSURYLVLRQLVYRLG
6XEVHFWLRQGRHVQRWDIIHFWDQDJUHHPHQWWRVXEPLWDGLVSXWHRU
GLIIHUHQFHWRDUELWUDWLRQLIWKHDJUHHPHQWZDVPDGHDIWHUWKHGLVSXWH
RUGLIIHUHQFHDURVH
,W LV QRWDEOH WKDW FRQWUDFWV RI PDULQH ,QVXUDQFH IUHTXHQWO\ FRQWDLQ
DUELWUDWLRQFODXVHVDQGDVWKH,QVXUDQFH&RQWUDFWV$FWGRHVQRWDSSO\
WR PDULQH LQVXUDQFH VHFWLRQ KDV QR HIIHFW RQ VXFK SURYLVLRQV LQ
PDULQHLQVXUDQFH+RZHYHUIRUWKHEXONRILQVXUDQFHFRQWUDFWVZULWWHQ
LQ$XVWUDOLDVHFWLRQKDVDGLUHFWHIIHFWEXWDVWKHSURYLVLRQQRWHV
LWVLPSDFWLVRQFRPSXOVRU\DUELWUDWLRQRQO\DQGGRHVQRWDIIHFWDSDUW\¶V
FDSDFLW\WRDJUHHWRDUELWUDWLRQDIWHUWKHGLVSXWHKDVDULVHQVXEVHFWLRQ
1RWZLWKVWDQGLQJWKHSURYLVLRQVRIVHFWLRQDQLQFUHDVLQJQXPEHURI
ODUJHU LQVXUDQFH GLVSXWHV LQ $XVWUDOLD DUH UHIHUUHG WR HLWKHU YROXQWDU\
DUELWUDWLRQ RU PHGLDWLRQ RU FRXUW GLUHFWHG PHGLDWLRQ RU FRQFLOLDWLRQ
,QGHHGPHGLDWLRQLVQRZDQLQWHJUDOSDUWRIWKHOLWLJDWLRQSURFHVV
7KH GULYH IRU PHGLDWLRQ FRQFLOLDWLRQ DQG DUELWUDWLRQ KDV DULVHQ LQ
FRQMXQFWLRQ ZLWK WKH MXGLFLDU\ H[SUHVVLQJ FRQFHUQV DV WR GHOD\V LQ
'HVLJQHGWRRYHUFRPHWKHLPSDFWRIWKH+RXVHRI/RUGVGHFLVLRQLQ6FRWWY$YHU\
/-([7KH&UWVGHFLVLRQZDVWKDWDFODXVHLQDFRQWUDFWRILQVXUDQFHZKLFKPDGH
VXEPLVVLRQRIDGLVSXWHXQGHUWKHFRQWUDFWWRDUELWUDWLRQDFRQGLWLRQSUHFHGHQWWROLDELOLW\
ZDVHIIHFWLYHWRH[FOXGHWKHFRXUW¶VMXULVGLFWLRQXQWLOWKHPDWWHUKDGEHHQDUELWUDWHG
&KULVWRSKHU5RGG
OLWLJDWLRQDQGWKHHVFDODWLQJFRVWVDVVRFLDWHGZLWKFRQYHQWLRQDOOLWLJDWLRQ
6LQFHWKHWXUQRIWKHQHZPLOOHQQLXPWKHUHKDVEHHQDSXVKIRULQFUHDVHG
VXSSRUW IRU WKH MXGLFLDO FDVH PDQDJHPHQW RI GLVSXWHV 7KH WUDGLWLRQDO
FRPPRQ ODZ DGYHUVDULDO DSSURDFK WR OLWLJDWLRQ KDV JLYHQ ZD\ WR DQ
LQFUHDVHGLQWHUYHQWLRQLVWDSSURDFKIURPWKHMXGLFLDU\WREHFRPHDFWLYHO\
LQYROYHGLQFDVHPDQDJHPHQW,QDOOMXULVGLFWLRQVERWKVWDWHDQGIHGHUDO
DQGZLWKWKHDVVLVWDQFHDQGVXSSRUWRIHPSRZHULQJOHJLVODWLRQMXGJHV
EHJDQRUGHULQJSDUWLHVWRPHGLDWLRQDVDQDOWHUQDWLYHGLVSXWHUHVROXWLRQ
PHFKDQLVP7KHGULYLQJPRWLYDWLRQIRUWKLVDSSURDFKLVWRIDFLOLWDWHWKH
MXVWTXLFNDQGFKHDSHUUHVROXWLRQRIWKHUHDOLVVXHVLQGLVSXWH
$V DQ LOOXVWUDWLRQ WKH 16: &LYLO 3URFHGXUH $FW40 HPSRZHUV WKH &RXUW
WR RUGHU WKH SDUWLHV WR SDUWLFLSDWH LQ PHGLDWLRQ LQ FDVHV ZKHUH LW LV
GHHPHGE\WKH&RXUWWREHDSSURSULDWH7KH&RXUWDSSRLQWVDPHGLDWRU
LQGHIDXOWRIDJUHHPHQWEHWZHHQWKHSDUWLHV
5HÀHFWLQJWKHDSSURDFKWDNHQE\WKH$XVWUDOLDQVWDWHOHJLVODWXUHVWKH
)HGHUDO*RYHUQPHQWHQDFWHGVLPLODUOHJLVODWLRQWRDSSO\WRWKH)HGHUDO
&RXUW±7KH'LVSXWH5HVROXWLRQ$FW7KLVOHJLVODWLRQUHTXLUHVWKH
SDUWLHVWROLWLJDWLRQWR¿OHD³JHQXLQHVWHSVVWDWHPHQW´DWWKHWLPHRI
LVVXLQJSURFHHGLQJV7KHVWDWHPHQWUHTXLUHVHDFKSDUW\WROLVWWKHVWHSV
WDNHQWRWU\WRUHVROYHWKHGLVSXWHSULRUWR¿OLQJ7KHREOLJDWLRQDSSOLHV
WRDOOSDUWLHVWRWKHOLWLJDWLRQ
2QHRIWKHREYLRXVDGYDQWDJHVRIPHGLDWLRQLILWLVQRWFRPSXOVRU\LV
WKDWE\EHLQJFRQVHQVXDOLWUHÀHFWVWKHSDUWLHV¶ZLOOLQJQHVVWRFRQVLGHU
QRQDGYHUVDULDOUHVROXWLRQ7KHFULWLFLVPWKDWWHQGVWRRFFXUZKHQLWLV
FRXUW GLUHFWHG LV WKDW WKH SDUWLHV PD\ QRW EH ZLOOLQJ SDUWLFLSDQWV DQG
DFFRUGLQJO\ WKH RSSRUWXQLW\ IRU D VXFFHVVIXO RXWFRPH LV SRWHQWLDOO\
GLPLQLVKHG 7KH OHJLVODWLRQ UHTXLUHV WKH SDUWLHV WR D PHGLDWLRQ WR
SDUWLFLSDWHLQ³JRRGIDLWK´41EXWWKHUHLVQRVDQFWLRQLPSRVHGRQDSDUW\
ZKRIDLOVWRGRVR*LYHQWKHQDWXUHRIWKHSURFHVVDQRWKHUFULWLFLVP
RIWHQOHYHOOHGUHODWHVWRWKHVHOHFWLRQRIPHGLDWRUV3DUWLHVWRDPHGLDWLRQ
VHOHFWLQJRQO\WKRVHPHGLDWRUV³V\PSDWKHWLF´WRWKHLUSRVLWLRQRUYLHZ
SRLQWFDQFUHDWHDQREVWDFOHWRUHVROXWLRQ
,QUHODWLRQWR$UELWUDWLRQPDQ\RIWKHFULWLFLVPVOHYHOOHGDWPHGLDWLRQDUH
MXVWDVUHOHYDQWRUDSSOLFDEOHWRDUELWUDWLRQ7KDWVDLGWKH&RXUWVKDYHVKRZQ
VWURQJVXSSRUWIRUDUELWUDWLRQE\HQIRUFLQJDUELWUDWRUVDZDUGVDVLILWZDVD
MXGJHPHQWRIWKHFRXUW+RZHYHULWDSSHDUVWKDWWKH&RXUWVDUHUHOXFWDQWWR
6HH8QLIRUP&LYLO3URFHGXUH5XOHV16:ZLWKVLPLODUOHJLVODWLRQLQRWKHU$XVWUDOLDQ
VWDWHVDQGWKH)HGHUDO&RXUW
40
6HH6HFWLRQ±&LYLO3URFHGXUH$FW16:
41
%\ZD\RILOOXVWUDWLRQVHH6HFWLRQRIWKH&LYLO3URFHGXUH$FW16:
64
UHOLQTXLVKDOOFRQWURORYHUWKHSURFHVVDQGLQWKH9LFWRULDQ&RXUWRI$SSHDO
GHFLVLRQLQ2LO%DVLQV/WGY%+3%LOOLWRQ/WG42WKH&RXUWKHOGWKDWZKHUHWKH
$UELWUDWRUIDLOHGWRSURYLGHDGHTXDWHUHDVRQVIRUKLVGHFLVLRQRUWKHUHDVRQV
ZHUH³QRWRIDQDFFHSWDEOHVWDQGDUG´WKLVPD\DPRXQWWRDQHUURURIODZ
UHVXOWLQJ LQ WKH RYHUWXUQLQJ RI WKH DUELWUDWRU¶V DZDUG 7KH UHVHUYDWLRQ RI
MXGLFLDOSRZHUWRLQWHUYHQHLVUHÀHFWHGLQWKHOHJLVODWLRQ
7KHDSSURDFKRIWKHFRXUWVWRDUELWUDWLRQLVGLFWDWHGE\WKHOHJLVODWLYHUHIRUPV
WKDWKDYHEHHQHQDFWHGWKURXJKRXW$XVWUDOLD7KH6WDQGLQJ&RPPLWWHHRI
$WWRUQH\V*HQHUDOLQIRUPXODWHGDQHZGRPHVWLFDUELWUDWLRQUHJLPH
PRGHOOHGXSRQWKH81&,75$/0RGHO/DZRQ,QWHUQDWLRQDO&RPPHUFLDO
DUELWUDWLRQ0RGHO/DZ7KHUHVXOWLQJOHJLVODWLRQZDVHVVHQWLDOO\FRQVLVWHQW
WKURXJKRXWWKHYDULRXVVWDWHMXULVGLFWLRQV&RPPHUFLDO$UELWUDWLRQ$FWV
&$$8VLQJWKH&RPPHUFLDO$UELWUDWLRQ$FW16:DVDQH[DPSOH
ULJKWV RI DSSHDO DJDLQVW DQ DUELWUDWRU¶V GHFLVLRQ DUH OLPLWHG 6HFWLRQ $
SURKLELWV DQ DSSHDO XQOHVV ERWK SDUWLHV FRQVHQW (YHQ ZKHUH FRQVHQW LV
JLYHQSXUVXDQWWR$WKHSDUW\VHHNLQJWRDSSHDOPXVWREWDLQOHDYH7KH
OHJLVODWLRQDOVRUHTXLUHVWKDWDSSOLFDWLRQVIRUOHDYHEHGHWHUPLQHGZLWKRXW
DKHDULQJXQOHVVWKHFRXUWGHWHUPLQHVWKDWDKHDULQJLVQHFHVVDU\6
SHUPLWVDQDSSHDOEXWUHTXLUHVDVHULRXVHUURURIDMXULVGLFWLRQDOQDWXUH
WREH5HFRXUVHWRDVXFFHVVIXODSSHDOZLOOQRWEHSHUPLWWHGXQOHVVLWFDQ
EHVKRZQWKHDUELWUDWRUVGLGQRWKDYHMXULVGLFWLRQRUIDLOHGWRH[HUFLVHWKH
MXULVGLFWLRQFRUUHFWO\(YHQLIVXFKPDWWHUVDUHPDGHRXWWKHFRXUWVWLOOUHWDLQV
DQRYHUULGLQJGLVFUHWLRQDVWRZKHWKHUWKHUHZLOOEHDQ\FRQVHTXHQFH
)XUWKHUPRUHEHIRUHGHWHUPLQLQJZKHWKHUWKHDZDUGVKRXOGEHVHWDVLGH
DWWKHUHTXHVWRIHLWKHUSDUW\DFRXUWPD\SXUVXDQWWRVDQG$
DQG VXVSHQG LWV RZQ SURFHVV IRU D WLPH WR HQDEOH WKH DUELWUDWRU WKH
RSSRUWXQLW\WRUHVXPHDUELWUDOSURFHHGLQJVRUWDNHRWKHUDFWLRQWRUHFWLI\
WKHDFWLRQWKDWSURYLGHGWKHJURXQGVWRVHWDVLGHWKHDZDUG
7KHOHJLVODWLYHLQWHQWLRQRIWKH&$$PDNHVLWFOHDUWKDWFRXUWLQWHUYHQWLRQ
LQDUELWUDWLRQVKRXOGEHPLQLPLVHGDQGWKDWWKHSDUDPRXQWFRQVLGHUDWLRQ
RIWKHOHJLVODWXUHLVWKH¿QDOLW\RIWKHDUELWUDOGHFLVLRQV7KH&$$LOOXVWUDWHV
WKHVKLIWLQDWWLWXGHWRZDUGVDJUHDWHUDFFHSWDQFHRIDUELWUDWLRQDVDGLVSXWH
UHVROXWLRQPHFKDQLVP
,Q UHODWLRQ WR DUELWUDWLRQ LQ $XVWUDOLD WKH FRQFOXGLQJ UHPDUNV RI WKH +RQ
-XVWLFH &O\GH &URIW GHOLYHUHG DW DQ DUELWUDWRU¶V FRQIHUHQFH LQ /RQGRQ LQ
DUHZRUWKUHSHDWLQJ
³WKHVHUHIRUPVHQVXUHWKDWWKHGRPHVWLFDQGLQWHUQDWLRQDODUELWUDOUHJLPHV
LQ$XVWUDOLDDUHXQL¿HGDQGKHQFHEROVWHUERWKLQWHUQDWLRQDODQGGRPHVWLF
DUELWUDWLRQVZLWKWKHSURPLVHRIFRQVLVWHQWXQLIRUPLQWHUSUHWDWLRQ
42
95
&KULVWRSKHU5RGG
1RQHWKHOHVVWKHLPSRUWDQFHRILPSDUWLDOHI¿FLHQWDFFHVVLEOHVXSSRUWLYH
DQG ³DUELWUDWLRQ IULHQGO\´ FRXUWV FDQQRW EH RYHU VWDWHG ,Q WKLV FRQWH[W
DOO LQYROYHG LQ WKH DUELWUDWLRQ KDYH D UROH WR SOD\ &UXFLDO DOVR LV WKH
UROHRIWKHDUELWUDWRUVDQGDUELWUDOLQVWLWXWLRQVLQDGRSWLQJÀH[LEOHWLPHO\
DQG LQQRYDWLYH SURFHVVHV WR PD[LPLVH HI¿FLHQF\ RI DUELWUDO GLVSXWHV %XLOGLQJ DQG PDLQWDLQLQJ D UHSXWDWLRQ DV D VWURQJ DUELWUDO MXULVGLFWLRQ
UHTXLUHV FRQVWDQW UHLQIRUFHPHQW ZLWK SRVLWLYH DQG SURDFWLYH PHDVXUHV
E\OHJLVODWXUHVJRYHUQPHQWVDUELWUDO ERGLHV DUELWUDWLRQ SUDFWLWLRQHUVDV
ZHOODVWKHMXGLFLDU\*LYHQWKHJURZWKRIDUELWUDWLRQDFURVVWKHJOREHLQ
UHFHQW\HDUVWKHZD\LQZKLFKWKHVHGLVSXWHVDUHKDQGOHGZLOOLQÀXHQFH
WKHRQJRLQJGHYHORSPHQWRIFRPPHUFLDODUELWUDWLRQ´
Conclusions
7KH IRUPV RI DOWHUQDWLYH GLVSXWH UHVROXWLRQ PHFKDQLVPV DYDLODEOH LQ
$XVWUDOLD WR GHDO ZLWK LQVXUDQFH GLVSXWHV DUH ZLGH DQG YDULHG SURYLGLQJ
ERWKWKHLQGXVWU\DQGFRQVXPHUVZLWKDQXPEHURIRSWLRQVWKDWZHUHVLPSO\
XQDYDLODEOH\HDUVDJR$'5KDVSURJUHVVHGDORQJZD\GXULQJWKLVSHULRG
DQGDOOLHGWRWKHFRQVXPHUUHIRUPVHPERGLHGLQWKH,QVXUDQFH&RQWUDFWV
$FWVXJJHVWWKDWWKHHQYLURQPHQWIRULQVXUHGVLVGHFLGHGO\PRUH
³FRQVXPHU FHQWULF´ $'5 LV QRZ DQ LQWHJUDO SDUW RI LQVXUDQFH GLVSXWH
UHVROXWLRQ ZLWK ERWK LQVXUHUV DQG LQVXUHGV DZDUH WKDW $'5 LV QRW RQO\
FRVW HIIHFWLYH DQG LPSRUWDQWO\ OHVV DGYHUVDULDO EXW DW WKH VDPH WLPH
PRUHH[SHGLWLRXVWKDQWUDGLWLRQDOOLWLJDWLRQ,QWKHFDVHRIFRQFLOLDWLRQDQG
PHGLDWLRQEHFDXVHDOOSDUWLHVDUHUHTXLUHGWRSDUWLFLSDWHLQJRRGIDLWKWKH
SRWHQWLDOWRSURGXFHDQRXWFRPHWKDWVDWLV¿HVWKHFRPSHWLQJLQWHUHVWVRI
DOOSDUWLHVLVVLJQL¿FDQWO\HQKDQFHG$'5LQDOOLWVPDQLIHVWDWLRQVLVIRU
LQVXUDQFHGLVSXWHVKHUHWRVWD\
$VWKHFXUUHQW$,'$3UHVLGHQW0LFKDHO*LOOREVHUYHGLQDSUHVHQWDWLRQDWD
UHFHQW$,'$FRQIHUHQFH
³7KHFRQFHSWRIEDODQFLQJWKHLQWHUHVWVRIDOOSDUWLFLSDQWVLQWKHLQVXUDQFH
LQGXVWU\ ZKLFK KDV EHHQ FHQWUDO WR $XVWUDOLD¶V UHFHQW UHIRUPV LQFOXGLQJ
WKRVH LQ UHODWLRQ WR DOWHUQDWLYH GLVSXWH UHVROXWLRQ KDV XQLYHUVDO DSSHDO
,Q $XVWUDOLD WKH FRQFHSW RI D ³IDLU JR IRU DOO´ VLWV DW WKH FHQWUH RI RXU
FXOWXUH´44
³&RPPHUFLDO $UELWUDWLRQ LQ $XVWUDOLD 7KH SDVW WKH SUHVHQW DQG WKH IXWXUH´ 7KH +RQ
-XVWLFH&O\GH&URIWSDSHUGHOLYHUHGDWDPHHWLQJRIWKH&KDUWHUHG,QVWLWXWHRI$UELWUDWRUV
/RQGRQ0D\th
44
³8VLQJDQG$YRLGLQJWKH&RXUW6\VWHPWR5HVROYH5H,QVXUDQFH'LVSXWHVWKH$XVWUDOLDQ
([SHULHQFH´$,'$%XGDSHVW&ROORTXLXP1RYHPEHU0LFKDHO*LOO
66
Resolving Consumer Insurance
Complaints in the UK - The Financial
Ombudsman Service
Michael Mendelowitz
Consultant, Norton Rose Fulbright LLP, London*
0LFKDHO 0HQGHORZLW] LV D FRQVXOWDQW LQ 1RUWRQ 5RVH )XOEULJKW·V LQVXUDQFH DQG
reinsurance practice. His experience covers a wide spectrum of classes of business,
including international casualty and property catastrophe, marine, aerospace, professional
indemnity and products liability. He specialises in disputes over contract interpretation,
materiality of underwriting information, environmental and other long tail liability issues,
and insurer insolvency. He is also regularly involved in non-contentious work, such as
alternative risk transfer transactions and contract negotiation and drafting. Michael is an
H[SHULHQFHGDUELWUDWRUKDYLQJEHHQDSSRLQWHGRQVRPHGR]HQRFFDVLRQVWRDUELWUDOSDQHOV
KHDULQJLQWHUQDWLRQDOUHLQVXUDQFHGLVSXWHV+HZDVIRU\HDUVWKHSULQFLSDOFRDXWKRU
and editor of a major loose-leaf textbook on reinsurance practice and the law and has
written numerous articles for legal and trade journals. Michael is a frequent speaker at
FRQIHUHQFHVLQWKH8.DQGRYHUVHDV)URPWRKHZDVWKH$VVLVWDQW6HFUHWDU\
*HQHUDO$GPLQLVWUDWLRQRIWKH$VVRFLDWLRQ,QWHUQDWLRQDOHGH'URLWGHV$VVXUDQFHVDQG
LVQRZDQKRQRUDU\OLIHPHPEHURIWKH$VVRFLDWLRQ0LFKDHOLVUHFRPPHQGHGDVDOHDGLQJ
individual in insurance and reinsurance by the major legal directories. He has consistently
EHHQQDPHGDVRQHRIWKHPRVWUHVSHFWHGSUDFWLWLRQHUVLQKLVÀHOGLQWHUQDWLRQDOO\LQWKH
Guide to the World’s Leading Insurance and Reinsurance Lawyers, and every edition of
The International Who’s Who of Business Lawyers since 2005 has put him in the world’s
top ten insurance and reinsurance lawyers.
Historical introduction1
7KHRULJLQDO8.LQVXUDQFHRPEXGVPDQZDVDSULYDWHHQWHUSULVHFUHDWHGE\
WKHLQVXUDQFHLQGXVWU\LWVHOI$,'$FDQOD\FODLPWREHLQJDWOHDVWLQGLUHFWO\
RQHRIWKHLQÀXHQFHVEHKLQGLWVFUHDWLRQ
7KH %ULWLVK ,QVXUDQFH /DZ $VVRFLDWLRQ WKH 8. FKDSWHU RI $,'$ KHOG D
* 7KLVDUWLFOHLVEDVHGXSRQDSUHVHQWDWLRQJLYHQE\WKHDXWKRUWRWKHWZHOIWK$,'$%XGDSHVW
,QVXUDQFH&ROORTXLXPRQ1RYHPEHU7KHSUHVHQWDWLRQKDVEHHQPRGL¿HGLQIRUPIRU
WKLVSXEOLFDWLRQDQGLWVVXEVWDQFHXSGDWHGVRWKDWWKHODZLVVWDWHGDVDW-DQXDU\
1
7KHIROORZLQJDFFRXQWLVEDVHGXSRQDQDUWLFOHE\3HWHU-7\OGHVOH\HQWLWOHG³7KH,QVXUDQFH
2PEXGVPDQ %XUHDX ± WKH HDUO\ KLVWRU\´ SXEOLVKHG LQ Journal of Insurance
Research and Practice SS DYDLODEOH RQ 0U 7\OGHVOH\¶V ZHEVLWH KWWSZZZ
SHWHUMW\OGHVOH\FRm
0LFKDHO0HQGHORZLW]
FROORTXLXPLQ-XO\RQWKHWKHPHRI³,QVXUDQFHDQGWKH&RQVXPHU´
DW ZKLFK VSHDNHUV IURP %HOJLXP )UDQFH WKH 1HWKHUODQGV 1RUZD\ DQG
6ZLW]HUODQG GLVFXVVHG WKH VXFFHVV RI LQGHSHQGHQW FRPSODLQWV V\VWHPV
LQ WKHLU UHVSHFWLYH MXULVGLFWLRQV 7KH 1RUZHJLDQ VSHDNHU +DQV 3HWWHU
/XQGJDDUGZDVUHIHUUHGWRLQWKHFROORTXLXPGRFXPHQWVDV³WKHLQVXUDQFH
RPEXGVPDQ´2 ± DQG LQGHHG WKH HW\PRORJLFDO URRW RI WKH WHUP LV DQ ROG
1RUVHZRUGPHDQLQJ³PHVVHQJHU´
2QHRIWKHGHOHJDWHVDWWKH%,/$FROORTXLXPZDV0LNH+DUULVRI*XDUGLDQ
5R\DO ([FKDQJH *5( ZKRVH LPDJLQDWLRQ ZDV FDXJKW E\ WKH LGHDV
SXW IRUZDUG E\ WKH VSHDNHUV ,Q 6HSWHPEHU 0U +DUULV ZURWH D
PHPRUDQGXPUHFRPPHQGLQJWKHFUHDWLRQRID8.LQVXUDQFHRPEXGVPDQ
7KH URDG WR IXO¿OPHQW RI WKLV FRQFHSW SURYHG WR EH VRPHZKDW ORQJ DQG
URFN\ EXW LQ WKH ,QVXUDQFH 2PEXGVPDQ %XUHDX ,2% FDPH LQWR
EHLQJLWZDVWKHYROXQWDU\FUHDWLRQRIWKUHHOHDGLQJLQVXUDQFHFRPSDQLHV
*5(*HQHUDO$FFLGHQWDQG5R\DO,QVXUDQFHZLWKRWKHULQVXUHUV±EXWE\
QRPHDQVWKHZKROHRIWKH8.PDUNHW±MRLQLQJRYHUWKHQH[WIHZ\HDUV
Overview
7KHSUHVHQW)LQDQFLDO2PEXGVPDQ6HUYLFH)26LVWKHFUHDWLRQRIDVWDWXWH
QDPHO\WKH)LQDQFLDO6HUYLFHVDQG0DUNHWV$FW³)60$´7KH)26
WRRNRYHUZLWKDQH[SDQVLRQRIWKHIXQFWLRQVRIWKH,2%ZLWKHIIHFWIURP
'HFHPEHU 7KH VFRSH RI WKH )26¶V ZRUN LV ZLGH FRYHULQJ PRVW
¿QDQFLDO VHUYLFHV PDWWHUV LQFOXGLQJ DSDUW IURP LQVXUDQFH FRPSODLQWV
DERXW PRUWJDJHV LQYHVWPHQW DGYLFH DQG FRQVXPHU FUHGLW :LWKLQ WKH
)26 VHSDUDWH WHDPV GHDO ZLWK IRU H[DPSOH UHWDLO EDQNLQJ SHQVLRQV
LQVXUDQFHVWRFNVDQGVKDUHVDQGRWKHULQYHVWPHQWV
7KH )26 LV EHOLHYHG WR EH WKH ODUJHVW RPEXGVPDQ VHUYLFH LQ WKH ZRUOG
WRGD\4,WVODWHVWDQQXDOUHYLHZZKLFKJLYHVVWDWLVWLFVIRUWKH¿QDQFLDO\HDU
FRPPHQFLQJRQ$SULODQGHQGLQJRQ0DUFKVKRZVWKDW
% WKH)26UHFHLYHGLQLWLDOFRPSODLQWVDQGHQTXLULHV±RYHU
HDFKZRUNLQJGD\
% DERXWRQHLQIRXULQLWLDODSSURDFKHVWXUQHGLQWRDIRUPDOGLVSXWH±D
UHFRUGQHZFDVHV
% FDVHVZHUHUHVROYHGE\DGMXGLFDWRUVDQG
2
+LVRI¿FLDOWLWOHZDVKHDGRIWKH1RUZHJLDQ%XUHDXIRU,QVXUDQFH'LVSXWHV
6HH3DUW;9,VHFWLRQVWR$DQG6FKHGXOH
4
See hWWSZZZSHWHUMW\OGHVOH\FRPIRVLQVXUDQFHSDJHVEDFNJURXQGKWPl
3XEOLVKHGRQLWVZHEVLWHhWWSZZZ¿QDQFLDORPEXGVPDQRUJXk
5HVROYLQJ&RQVXPHU,QVXUDQFH&RPSODLQWVLQWKH8.«
E\RPEXGVPHQ6UHVXOWLQJLQFRPSHQVDWLRQIRUFRQVXPHUVLQ
RIFRPSODLQWV
% WKH )26 RSHUDWHG RQ D EXGJHW RI PLOOLRQ ZLWK DERXW HPSOR\HHV
% LQIRUPDWLRQZDVSURYLGHGDQGHQTXLULHVKDQGOHGLQRYHUGLIIHUHQW
ODQJXDJHVDQGIRUPDWV
&RQ¿GHQWLDOLW\LVDVVXUHGGXULQJWKHFRPSODLQWSURFHVVDOWKRXJKFRPSODLQWV
RIJHQHUDOLQWHUHVWPD\EHFRPHVXEMHFWVIRUFDVHVWXGLHVSXEOLVKHGRQDQ
DQRQ\PRXV EDVLV LQ Ombudsman News 7KLV SXEOLFDWLRQ KDV DSSHDUHG
UHJXODUO\VLQFH-DQXDU\,WZDVRULJLQDOO\DPRQWKO\MRXUQDODOWKRXJK
LWQRZFRPHVRXWOHVVIUHTXHQWO\7KHODWHVWLVVXHDWWKHWLPHRIZULWLQJLV
LVVXHGDWHG'HFHPEHUVRWKHDYHUDJHLVRQHLVVXHDERXWHYHU\
VL[ZHHNV
Jurisdiction
7KH )26 KDV ERWK FRPSXOVRU\ DQG YROXQWDU\ MXULVGLFWLRQ (QWLWLHV WKDW
DUHUHJXODWHGE\WKH)LQDQFLDO&RQGXFW$XWKRULW\RU)&$WKDWLVWKHDUP
RI WKH 8. ¿QDQFLDO VHUYLFHV VXSHUYLVRU ZLWK UHVSRQVLELOLW\ IRU LQWHU DOLD
FRQVXPHUSURWHFWLRQDUHUHTXLUHGWRFRRSHUDWHZLWKWKH)26DQGFRPSO\
ZLWKLWVGHFLVLRQV6XFKUHJXODWHGHQWLWLHVLQFOXGHDOOLQVXUHUVDXWKRULVHG
WRFRQGXFWEXVLQHVVLQWKH8.
7KH)26¶VYROXQWDU\MXULVGLFWLRQDSSOLHVWREXVLQHVVHVWKDWDUHSHUPLWWHG
WR VLJQ XS WR WKH )26 VFKHPH LQ UHVSHFW RI FRPSODLQWV QRW FRYHUHG E\
WKHFRPSXOVRU\MXULVGLFWLRQIRUH[DPSOHEDQNVDQGLQVXUDQFHFRPSDQLHV
WKDW DUH EDVHG LQ RQH RI WKH PHPEHU VWDWH RI WKH (XURSHDQ 8QLRQ DQG
WKDW DUH QRW UHJXODWHG E\ WKH )&$ EXW WKDW GHDO SUHGRPLQDWHO\ ZLWK 8.
FRQVXPHUV 2WKHU EXVLQHVV WKDW KDYH VLJQHG XS YROXQWDULO\ WR WKH )26
MXULVGLFWLRQ LQFOXGH WKH 3RVW 2I¿FH LQ UHVSHFW RI IRU H[DPSOH GLVSXWHV
DERXW SXUFKDVH RI IRUHLJQ FXUUHQF\ RQOLQH SD\PHQW VHUYLFHV VXFK DV
3D\3DO IUHLJKW IRUZDUGHUV DQG VWRUDJH FRPSDQLHV %XVLQHVVHV VXEMHFW
WR )26 MXULVGLFWLRQ ZKHWKHU FRPSXOVRULO\ RU YROXQWDULO\ DUH KHQFHIRUWK
UHIHUUHGWRXVLQJWKH)26¶VRZQWHUPLQRORJ\DV³VXEMHFW¿UPV´
7KH)26¶VMXULVGLFWLRQLVOLPLWHGLQ¿QDQFLDOWHUPVWKHPD[LPXPDPRXQW
WKDW LW FDQ DZDUG DV FRPSHQVDWLRQ LV ZKLFK ZDV LQFUHDVHG
IURPWKHSUHYLRXVOLPLWRILQ-DQXDU\,WVKRXOGEHQRWHG
KRZHYHUWKDWDOWKRXJKWKHOLPLWRI)26DZDUGVWKDWFDQEHHQIRUFHGLQFRXUW
LVSDUWLHVZKRFRPHEHIRUHWKH)26PD\DVNIRUDQRQELQGLQJ
6
6HHWKHGHVFULSWLRQRIWKH)26¶VSURFHVVHVLQWKHVHFWLRQKHDGHG³3URFHGXUHÉHORZ
7KH FXUUHQW LVVXH DQG SUHYLRXV LVVXHV RI Ombudsman News PD\ EH IRXQG RQ WKH )26
ZHEVLWH
0LFKDHO0HQGHORZLW]
UHFRPPHQGDWLRQZKHQWKHDPRXQWDWVWDNHLVKLJKHU±DQGREYLRXVO\DQ\
VXFKUHFRPPHQGDWLRQWKDWWKH)26LVZLOOLQJWRPDNHLVOLNHO\WRKDYHD
SRZHUIXOLQÀXHQFHLQDQ\VXEVHTXHQWVHWWOHPHQWQHJRWLDWLRQV
$OWKRXJK WKH VHUYLFHV SURYLGHG E\ WKH )26 DUH DLPHG SUHGRPLQDQWO\ DW
SULYDWH LQGLYLGXDOV LW LV RQ WKH RQH KDQG QRW HYHU\ LQGLYLGXDO ZKR FDQ
WDNHKLVRUKHUFDVHWRWKH)26DQGRQWKHRWKHUWKH)26¶VMXULVGLFWLRQ
GRHVH[WHQGWRFHUWDLQVPDOOEXVLQHVVHV±EXWWKHUHDUHOLPLWV
7KH H[FHSWLRQ UHODWLQJ WR SULYDWH LQGLYLGXDOV LV XQOLNHO\ WR KDYH PXFK
DSSOLFDWLRQ WR SROLF\KROGHUV ZKR ZLVK WR FRPSODLQ DERXW WKH ZD\ WKH\
KDYHEHHQWUHDWHGE\LQVXUDQFHFRPSDQLHVDUHJXODWHG¿UPFDQKRZHYHU
GLVSXWH WKH HQWLWOHPHQW RI VRFDOOHG ³SURIHVVLRQDO FOLHQWV´ WR EULQJ D
FRPSODLQW WR WKH )26 7KH FODVV RI ³SURIHVVLRQDO FOLHQWV´ LV OLNHO\ WR EH
FRQ¿QHG WR H[SHULHQFHG DQG VRSKLVWLFDWHG LQYHVWRUV ZKR ZLVK WR PDNH
FRPSODLQWVDERXWVWRFNEURNHUVRU¿QDQFLDODGYLVHUV
7KH)26FDQDOVRFRQVLGHUFRPSODLQWVIURPEXVLQHVVHVWKDWKDYHDQDQQXDO
WXUQRYHURIOHVVWKDQ¼DQGIHZHUWKDQHPSOR\HHV±WKH(8
WHUPIRUVXFKEXVLQHVVHVLV³PLFURHQWHUSULVHV´,WVKRXOGEHQRWHGWKDWIRU
WKH)26WRKDYHMXULVGLFWLRQERWKRIWKH³PLFURHQWHUSULVH´FULWHULDPXVW
EHVDWLV¿HG±WKH\DUHQRWDOWHUQDWLYHV
Funding
7KH VHUYLFH SURYLGHG E\ WKH )26 LV IUHH WR FRQVXPHUV WKDW LV FOLHQWV RI
VXEMHFW¿UPV7KH)26LVIXQGHGE\VXEMHFW¿UPVZKLFKSD\DQDQQXDO
OHY\ ± ZKRVH DPRXQW YDULHV GHSHQGLQJ RQ WKH QDWXUH DQG VL]H RI WKH
EXVLQHVV FRQFHUQHG ± DQG FDVH IHHV 7KH DQQXDO OHY\ FXUUHQWO\ UDQJHV
IURPDERXWIRUDVPDOO¿UPRI¿QDQFLDODGYLVRUVWRRYHUIRU
DKLJKVWUHHWEDQNRUDPDMRULQVXUDQFHFRPSDQ\
8QGHUWKHFXUUHQWDUUDQJHPHQWVEXVLQHVVHVDUHHQWLWOHGWRKDYHWKH¿UVW
FRPSODLQWVPDGHDJDLQVWWKHPGXULQJDQ\¿QDQFLDO\HDUKDQGOHGIUHHRI
FKDUJHEXWIRUWKHthDQGDQ\VXEVHTXHQWFDVHVDIHHRISHUFDVH
DSSOLHV&DVHIHHDUUDQJHPHQWVDUHUHYLHZHGDQQXDOO\DQGPD\FKDQJHLQ
IXWXUH
Procedure
$ VXEMHFW ¿UP PXVW EH JLYHQ DQ RSSRUWXQLW\ WR UHVROYH LWV FXVWRPHU¶V
FRPSODLQWEHIRUHWKH)26VWHSVLQ7KHQRUPDOSURFHGXUHLVDVIROORZV
7KH)26GRHVKRZHYHUKDYHWKHSRZHUWRFRQVLGHUZKHWKHUDVXEMHFW¿UP¶VFODVVL¿FDWLRQ
RIDSRWHQWLDOFODLPDQWDVD³SURIHVVLRQDOFOLHQW´LVDSSURSULDWHLIWKH)26GHWHUPLQHVWKDW
WKHFODVVL¿FDWLRQLVQRWDFFXUDWHLWFDQWKHQJRRQWRLQYHVWLJDWHWKHFRPSODLQW
% 7KHSURFHVVVWDUWVZLWKWKHFXVWRPHUVHQGLQJDOHWWHURIFRPSODLQW
WRWKHVXEMHFW¿UP
% 7KH¿UPWKHQKDVHLJKWZHHNVWRLQYHVWLJDWHWKHFRPSODLQWDQGLVVXH
DGHFLVLRQ
% ,I WKH FXVWRPHU LV QRW VDWLV¿HG ZLWK WKH ¿UP¶V GHFLVLRQ LW PD\
DSSURDFKWKH)26
7KHUH LV D WLPH OLPLW ZLWKLQ ZKLFK WKH FXVWRPHU PXVW DFW 1RUPDOO\ WKLV
LVVL[PRQWKVIURPWKHUHFHLSWRID¿QDOUHVSRQVHIURPWKH¿UPEXWWKDW
GHDGOLQHZLOOQRWDSSO\LIWKHUHDUH³H[FHSWLRQDOFLUFXPVWDQFHV´RULIWKH
¿UPGRHVQRWWHOOWKHFXVWRPHUWKDWKHRUVKHKDVVL[PRQWKVWRFRPSODLQ
WRWKH)26³([FHSWLRQDOFLUFXPVWDQFHV´DUHQRWGH¿QHGEXWDQH[DPSOH
JLYHQE\WKH)26RQLWVZHEVLWHLVLIWKHFRQVXPHULVLQFDSDFLWDWHGIRUWKH
SHULRGGXULQJZKLFKKHRUVKHVKRXOGKDYHFRPSODLQHG
7KH )26¶V SURFHGXUHV DUH DLPHG DW DFKLHYLQJ UHVROXWLRQ RI FRPSODLQWV
TXLFNO\DQGZLWKPLQLPXPIRUPDOLW\$FRPSODLQWZLOOLQLWLDOO\EHDVVLJQHG
WR DQ DGMXGLFDWRU ZKR ZLOO WU\ WR ¿QG D VROXWLRQ WKURXJK FRQFLOLDWLRQ RU
LQIRUPDOPHGLDWLRQLQFOXGLQJ±ZKHUHDSSURSULDWH±VSHDNLQJWRHDFKRIWKH
SDUWLHVE\WHOHSKRQH7KHDGMXGLFDWRUPD\UHTXHVWFODUL¿FDWLRQRUIXUWKHU
GRFXPHQWV ,I QHFHVVDU\ KH RU VKH ZLOO LVVXH D SUHOLPLQDU\ DVVHVVPHQW
DQGDVNWKHSDUWLHVWRFRPPHQW9HU\RIWHQWKHPDWWHUZLOOVHWWOHDWWKDW
VWDJH,IKRZHYHUWKHFRPSODLQWLVQRWUHVROYHGHLWKHUSDUW\PD\DVNIRU
DQRPEXGVPDQ¶VUHYLHZDQG¿QDOGHFLVLRQ7KHRPEXGVPDQZLOOUHYLHZDOO
RIWKHHYLGHQFHLQGHSHQGHQWO\DQGLVVXHDZULWWHQSURYLVLRQDODVVHVVPHQW
ZLWKDWLPHOLPLWIRUWKHSDUWLHVWRUHVSRQG2QO\DIWHUH[SLU\RIWKDWWLPH
OLPLWZLOOD¿QDOGHWHUPLQDWLRQEHLVVXHG
7KHFXVWRPHU¶VSUHVHQWDWLRQRIKLVRUKHUFRPSODLQWLVQRWMXGJHGE\WKH
VWDQGDUGV RI IRUPDO FRXUW SOHDGLQJV 7KH RPEXGVPDQ ZLOO DOZD\V ORRN
EH\RQGWKHIRUPRIDFRPSODLQWWRLWVVXEVWDQFH7KH)26KDVQRSRZHU
WRFRPSHOZLWQHVVHVWRDWWHQGKHDULQJVWRWDNHHYLGHQFHRQRDWKRUWR
SHUPLWDFRPSODLQWRUWKHUHVSRQVHWRDFRPSODLQWWREHWHVWHGE\FURVV
H[DPLQDWLRQ
Effect of FOS decision
7KH HIIHFW RI D )26 GHFLVLRQ LV GLIIHUHQW IRU VXEMHFW ¿UPV DQG IRU
FXVWRPHUV
,ID¿QDOGHFLVLRQJRHVLQIDYRXURIWKHFXVWRPHUDQGWKHFXVWRPHUDFFHSWV
LW WKDW GHFLVLRQ EHFRPHV ¿QDO DQG ELQGLQJ RQ ERWK SDUWLHV 7KHUH DUH
GHDGOLQHVIRUDFFHSWDQFHZKLFKZLOOEHVHWE\WKHRPEXGVPDQ7KH)26
ZHEVLWH GRHV QRW JLYH DQ\ LQIRUPDWLRQ RQ WKH VWDQGDUG OHQJWK RI WLPH ±
0LFKDHO0HQGHORZLW]
SUHVXPDEO\EHFDXVHHDFKFDVHZLOOEHWUHDWHGRQLWVRZQIDFWV±EXWWKH
W\SLFDOWLPHOLPLWDSSHDUVWREHEHWZHHQRQHPRQWKDQGVL[ZHHNV7KLVLV
FRQVLVWHQWZLWKWKH)26¶VVWDWHGDLPRIUHVROYLQJPRVWFRPSODLQWVZLWKLQD
IHZPRQWKVDOWKRXJKLWLVUHFRJQLVHGWKDWVRPHFODLPVPD\WDNHORQJHU
HLWKHUEHFDXVHRIWKHLULQKHUHQWFRPSOH[LW\RUEHFDXVHRIWKHVKHHUYROXPH
RIVLPLODUFODLPVWKDWWKH)26PD\KDYHWRGHDOZLWKDWDQ\RQHWLPH
,I WKH )26 UXOHV DJDLQVW WKH FRPSODLQDQW WKH FXVWRPHU LV QRW ERXQG WR
DFFHSWWKDWGHFLVLRQEXWFDQWDNHWKHPDWWHUWRWKHRUGLQDU\FRXUWV±VXEMHFW
RIFRXUVHWRFRQVLGHUDWLRQVVXFKDVWKHH[SLU\RIOLPLWDWLRQSHULRGV
7KHVXEMHFW¿UPRQWKHRWKHUKDQGKDVQRVXFKRSWLRQVLWZLOOHLWKHUEH
ERXQG E\ WKH FXVWRPHU¶V DFFHSWDQFH RI DQ RPEXGVPDQ GHFLVLRQ LQ WKH
FXVWRPHU¶VIDYRXURULIWKHRPEXGVPDQUXOHVLQIDYRXURIWKHVXEMHFW¿UP
LWZLOOVWLOOEHH[SRVHGWRWKHULVNWKDWWKHFXVWRPHUZLVKHVWRKDYHKLVRU
KHUFRPSODLQWKHDUGLQFRXUW
7KHUHPHGLHVDYDLODEOHIURPWKH)26DUHOLPLWHG7KH)26GRHVQRWKDYH
DQ\IXQGVRILWVRZQWRFRPSHQVDWHFXVWRPHUV,WGRHVKRZHYHUKDYHWKH
SRZHUWRRUGHUVXEMHFW¿UPVWRSD\FRPSHQVDWLRQWRFXVWRPHUVRUWRWDNH
RWKHUVWHSVIRUH[DPSOHWRDPHQGDQ\DGYHUWLVLQJZKLFKWKH)26FRQVLGHUV
PLVOHDGLQJ7KH)26FDQQRW¿QH¿UPVRUOHJLVODWHIRUWKHLUIXWXUHFRQGXFW
WKHVHIXQFWLRQVUHPDLQWKHSUHURJDWLYHRIWKH)&$
&RQÀLFWVEHWZHHQ)26DQG8.OHJDOV\VWHP±DQGWKHLUUHVROXWLRQ
7KHUHDUHIXQGDPHQWDOGLIIHUHQFHVRISULQFLSOHLQWKHDSSURDFKE\WKH)26
RQWKHRQHKDQGDQGWKHRUGLQDU\FRXUWVRQWKHRWKHUWR¿QDQFLDOVHUYLFHV
FRPSODLQWVFRPLQJEHIRUHHDFKRIWKHP7KH)26PDNHVLWVGHFLVLRQV³E\
UHIHUHQFHWRZKDWLVLQWKHRSLQLRQRIWKHRPEXGVPDQIDLUDQGUHDVRQDEOH
LQDOOWKHFLUFXPVWDQFHVRIWKHFDVH´7KH)26QHHGQRWDSSO\VWULFWUXOHV
RIFRQVWUXFWLRQLIWKHLUDSSOLFDWLRQZRXOGGHIHDWWKHOHJLWLPDWHVXEMHFWLYH
H[SHFWDWLRQV RI WKH FRQVXPHU 7KH RSHUDWLRQ RI WKLV SULQFLSOH LQ WKH
LQVXUDQFHFRQWH[WPHDQVWKDWVRPHFDVHVFRXOGEHWUHDWHGYHU\GLIIHUHQWO\
E\WKH)26DQGWKH(QJOLVKFRXUWV7KLVFDQSHUKDSVEHVWEHLOOXVWUDWHG
E\FRQVLGHULQJKRZWKH)26DQGWKHFRXUWVHDFKDSSURDFKFDVHVLQZKLFK
DQLQVXUHUKDVGHQLHGFRYHUDJHRQWKHJURXQGVWKDWWKHSROLF\KROGHUKDV
PDGHDPDWHULDOQRQGLVFORVXUHRUPLVUHSUHVHQWDWLRQ10
7KH VWULFW SRVLWLRQ XQGHU (QJOLVK ODZ ZKLFK ZLOO RI FRXUVH EH DSSOLHG E\
WKH FRXUWV LV WKDW DQ LQVXUHU WR ZKRP D PDWHULDO PLVUHSUHVHQWDWLRQ RU
QRQGLVFORVXUH KDV EHHQ PDGH PD\ DYRLG WKH SROLF\ IURP LWV LQFHSWLRQ
0DWHULDOLW\LVIRUWKHVHSXUSRVHVMXGJHGE\WKHVWDQGDUGRIWKH³SUXGHQW
)60$VHFWLRQ
10
$QH[DPSOHDSSHDUVEHORZLQWKHVHFWLRQKHDGHG³6HOHFWHGµZDUVWRULHV¶´
LQVXUHU´11WKHTXHVWLRQEHFRPHVZKHWKHUDSUXGHQWLQVXUHUZRXOGLIWKH
WUXHIDFWVKDGEHHQGLVFORVHGKDYHDFFHSWHGWKHULVNDQGLIVRRQZKDW
WHUPVSDUWLFXODUO\DVUHJDUGVWKHSUHPLXP8QGHUWKHWHVWODLGGRZQE\
WKHOHDGLQJFDVHRIPan Atlantic Insurance Co Ltd v Pine Top Reinsurance Co
Ltd,12WKHEDVLFWH[WUHPDLQVZKDWDSUXGHQWLQVXUHUZRXOGKDYHGRQHDOEHLW
WKDWWKHXQGHUZULWHUZKRDFWXDOO\ZURWHWKHULVNPXVWVKRZWKDWKHZRXOG
KDYH DFWHG GLIIHUHQWO\ KDG WKH WUXH IDFWV EHHQ GLVFORVHG RU UHSUHVHQWHG
7KLVFUHDWHVDQREYLRXVGLI¿FXOW\IRUWKHFRQVXPHUEX\LQJLQVXUDQFHZKR
FDQQRWEHSUHVXPHGWRNQRZZKDWZLOOLQÀXHQFHDQXQGHUZULWHUXQOHVVWKH
LQVXUDQFHFRPSDQ\±XVXDOO\LQDSURSRVDOIRUP±LOOXVWUDWHVE\PHDQVRI
UHOHYDQWTXHVWLRQVH[DFWO\ZKDWLWZDQWVWRNQRZ
7KH)26DSSURDFKE\FRQWUDVWVWDUWVIURPWKHSUDFWLFDOVWDQGSRLQWWKDW
WKHLQVXUHUVKRXOGPDNHFOHDUWRWKHZRXOGEHLQVXUHGZKDWWKHXQGHUZULWHU
ZDQWVWRNQRZ7KH)26ZLOODFFRUGLQJO\FRQVLGHUWKHIROORZLQJPDWWHUV
% 'LGWKHLQVXUHUDVNDFOHDUTXHVWLRQ"
% :DVWKHLQVXUHG¶VDQVZHULQDFFXUDWH"
% :DVWKHLQVXUHG¶VLQDFFXUDF\GHOLEHUDWHQHJOLJHQWRULQQRFHQW"
% 'LGWKHLQDFFXUDWHDQVZHULQÀXHQFHWKHLQVXUHU¶VGHFLVLRQ"
% :KDW ZRXOG WKH LQVXUHU KDYH GRQH LI WKH DQVZHU KDG EHHQ
DFFXUDWH"
7KH)26WKHQKDVDUDQJHRISRVVLEOHUHPHGLHVDWLWVGLVSRVDOLQFOXGLQJIRU
H[DPSOHWKHLPSRVLWLRQRIH[FOXVLRQVRURWKHUFRQGLWLRQVRURUGHULQJWKH
LQVXUHUWRPDNHDSDUWLDOSD\PHQWWRUHÀHFWWKHSRVVLELOLW\WKDWKDGWKH
LQVXUHUNQRZQWKHWUXWKLWZRXOGKDYHLPSRVHGDQLQFUHDVHGSUHPLXPRU
GHGXFWLEOH
,W LV WR EH QRWHG WKDW WKH )26 DSSURDFK KDV KDG D VLJQL¿FDQW LPSDFW
RQ FRQVXPHU LQVXUDQFH ODZ LQ WKH 8. LQ WKDW WKH &RQVXPHU ,QVXUDQFH
'LVFORVXUHDQG5HSUHVHQWDWLRQV$FWZKLFKFDPHLQWRIRUFHLQ$SULO
DEROLVKHV WKH GXW\ RI SUHFRQWUDFWXDO GLVFORVXUH IRU FRQVXPHUV
DQG UHSODFHV LW ZLWK D GXW\ WR DQVZHU DQ LQVXUHU¶V TXHVWLRQV FDUHIXOO\
DQGKRQHVWO\,QDGGLWLRQWKH$FWFUHDWHVWKHSRVVLELOLW\RIDPXFK
ZLGHU UDQJHRI UHPHGLHVIRU WKH LQVXUHUWKDQ WKH SUHYLRXV DOORUQRWKLQJ
HQWLWOHPHQW WR DYRLG WKH SROLF\ IURP LQFHSWLRQ 7KH ULJKW RI DYRLGDQFH
UHPDLQVIRUFDVHVLQZKLFKWKHXQGHUZULWHUZRXOGQRWKDGWKHUHQRWEHHQ
DQ\PLVUHSUHVHQWDWLRQKDYHDFFHSWHGWKHULVNDWDOOEXWLQRWKHUFDVHVWKH
11
$ FUHDWLRQ RI VWDWXWH WKH 0DULQH ,QVXUDQFH $FW VHFWLRQV DV UHJDUGV
QRQGLVFORVXUH DQG DV UHJDUGV PLVUHSUHVHQWDWLRQ DQG FRQVLGHUHG E\ VRPH
FRPPHQWDWRUVWREHDP\WKLFDO¿JXUH
12
>@$&+/
0LFKDHO0HQGHORZLW]
LQVXUHU¶VUHPHG\LVEDVHGXSRQZKDWWKHXQGHUZULWHUZRXOGDFWXDOO\KDYH
GRQHKDGWKHLQVXUHGDQVZHUHGWKHTXHVWLRQVWUXWKIXOO\LWFRXOGEHIRU
H[DPSOHWKHHIIHFWLYHUHZULWLQJRIWKHSROLF\WRLQVHUWDQH[FOXVLRQRUDQ
LQFUHDVHGGHGXFWLEOH)XUWKHULIWKHLQVXUHUZRXOGRQO\KDYHDFFHSWHGWKH
ULVNVXEMHFWWRDKLJKHUSUHPLXPWKHLQGHPQLW\SD\DEOHWRWKHLQVXUHGZLOO
EHSURSRUWLRQDWHO\UHGXFHG
Selected “war stories”
)RXU FDVH VWXGLHV SXEOLVKHG LQ Ombudsman News HDFK RQH WDNHQ IURP
D GLIIHUHQW PDUNHW VHFWRU PD\ KHOS WR LOOXVWUDWH KRZ WKH )26 ZRUNV LQ
SUDFWLFH
Travel insurance – policy construction
7KHFRPSODLQDQWPDGHDFODLPIRUFRPSHQVDWLRQIRUGHOD\XQGHUDWUDYHO
LQVXUDQFH SROLF\ IRU GHOD\ FDXVHG E\ WKH DVK FORXG SURGXFHG E\ WKH
HUXSWLRQ RI WKH (\MDIMDOODM|NXOO YROFDQR LQ ,FHODQG LQ 7KH LQVXUHU
GHQLHGLQGHPQLW\RQWKHJURXQGVWKDWWKHDVKFORXGGLGQRWFRQVWLWXWHD
³SRRU ZHDWKHU FRQGLWLRQ´ ZKLFK ZDV WKH UHOHYDQW SHULO LQVXUHG DJDLQVW
7KHRPEXGVPDQXSKHOGWKHLQVXUHG¶VFRPSODLQWRQWKHEDVLVWKDWDOWKRXJK
DYROFDQLFHUXSWLRQZDVQRWLWVHOIDZHDWKHUFRQGLWLRQDFORXGRIDVKERUQH
RQ WKH ZLQG ZDV LQFOXGHG ZLWKLQ WKH ZRUGV ³SRRU ZHDWKHU´ ZLWKLQ WKH
RUGLQDU\ DQG QDWXUDO PHDQLQJ RI WKRVH ZRUGV QRWZLWKVWDQGLQJ WKDW WKH
FORXGZDVFDXVHGE\WKHHUXSWLRQRIDYROFDQR7KHLQVXUHUZDVRUGHUHGWR
SD\WKHGHOD\HGSDVVHQJHUFRPSHQVDWLRQXQGHUWKHWUDYHOSROLF\
Health insurance – non-disclosure
$KHDOWKLQVXUDQFHSURSRVDOIRUPDVNHGWKHTXHVWLRQZKHWKHUWKHSURSRVHU
KDGHYHUVXIIHUHGIURP³EDFNRUVSLQDOWURXEOH´7KHLQVXUHGKDGLQIDFW
VXIIHUHG IURP DQG UHFHLYHG WUHDWPHQW IRU EDFN SDLQ IROORZLQJ FKLOGELUWK
DERXWWHQ\HDUVSUHYLRXVO\6KHGLGQRWKRZHYHUGLVFORVHWKLVLQIRUPDWLRQ
LQ WKH SURSRVDO IRUP EHFDXVH VKH GLG QRW EHOLHYH WKDW EDFN SDLQ GXH WR
FKLOGELUWKZDVWKHW\SHRI³EDFNRUVSLQDOWURXEOH´DERXWZKLFKWKHLQVXUHU
ZDQWHGWRNQRZ,QDGGLWLRQPRVWRIWKHTXHVWLRQVLQWKHSURSRVDOIRUP
EXWQRWWKHTXHVWLRQDERXWEDFNSDLQDVNHGIRULQIRUPDWLRQDERXWPHGLFDO
FRQVXOWDWLRQVWKDWKDGRFFXUUHGGXULQJWKHSUHYLRXV¿YH\HDUV7KHLQVXUHG
ODWHUGHYHORSHGEUHDVWFDQFHUFRPSOHWHO\XQUHODWHGWRKHUEDFNFRQGLWLRQ
7KHLQVXUHUWKHQOHDUQHGRIWKHEDFNSDLQDQGVRXJKWWRDYRLGWKHSROLF\IRU
QRQGLVFORVXUH7KH)26WRRNWKHYLHZWKDWWKHLQVXUHGKDGEHHQVOLJKWO\
FDUHOHVV LQ FRPSOHWLQJ WKH SURSRVDO IRUP EXW LI VKH KDG DQVZHUHG WKH
LQVXUHU¶VTXHVWLRQVFRPSOHWHO\DFFXUDWHO\WKHLQVXUHUZRXOGKDYHRIIHUHG
IXOO FRYHU H[FHSW IRU EDFN DQG VSLQDO SUREOHPV 7KH )26 DFFRUGLQJO\
UHTXLUHG WKH LQVXUHU WR UHLQVWDWH WKH SROLF\ VXEMHFW WR DQ H[FOXVLRQ IRU
VSLQDOFRQGLWLRQVDQGWRSD\WKHFRPSODLQDQW¶VEUHDVWFDQFHUFODLPLQIXOO
WRJHWKHUZLWKLQWHUHVW
Property insurance – warranties
$QLQWUXGHUEURNHLQWRWKHLQVXUHG¶V¿VKDQGFKLSVKRSDQGVWDUWHGD¿UH
7KHLQVXUHUFODLPHGWREHGLVFKDUJHGIURPOLDELOLW\EHFDXVHWKHLQVXUHGKDG
ZDUUDQWHG WKDW WKH GRRU RI WKH VKRS ZDV ¿WWHG ZLWK D ¿YH OHYHU PRUWLFH
ORFNZKHQLQIDFWWKHORFNKDGRQO\WKUHHOHYHUV7KH)26IRXQGWKDWWKH
W\SH RI ORFN PDGH QR GLIIHUHQFH WR WKH ORVV DV WKH LQWUXGHU KDG LQ IDFW
HQWHUHGWKHVKRSE\EUHDNLQJWKURXJKDSDQHOLQWKHGRRU$VWKHUHZDVQR
FDXVDOFRQQHFWLRQEHWZHHQWKHEUHDFKRIZDUUDQW\DQGWKHORVVWKHLQVXUHU
ZDVRUGHUHGWRSD\WKHLQVXUHG¶VFODLP
Property insurance – non-disclosure
7KH FRQVXPHU GRHV QRW KRZHYHU DOZD\V ZLQ GLVSXWHV VXEPLWWHG WR WKH
)26,QRQHFDVHWKHSROLF\KROGHULQVXUHGDVKRSZLWKDÀDWDERYHLW+H
GLGQRWGLVFORVHWKDWWKHWHQDQWRIWKHÀDWZDVXQVDWLVIDFWRU\LQDQXPEHU
RIUHVSHFWVDQGWKDWWKHSROLF\KROGHUKDGVWDUWHGSURFHHGLQJVDJDLQVWWKH
WHQDQW IRU UHSRVVHVVLRQ 7KH WHQDQW VWDUWHG D VHULRXV ¿UH LQ WKH ÀDW E\
VPRNLQJLQEHG7KH)26KHOGWKDWWKHLQVXUHUZDVMXVWL¿HGLQDYRLGLQJWKH
SROLF\IRUPDWHULDOQRQGLVFORVXUHHYHQWKRXJKQRVSHFL¿FTXHVWLRQVDERXW
WKHWHQDQF\RIWKHÀDWKDGEHHQDVNHG7KHLQVXUHGVKRXOGKDYHUHDOLVHG
WKDWWKHXQGHUZULWHUZRXOGZDQWWRNQRZDERXWSUREOHPWHQDQWV
FOS and proposed insurance contract law reform with regard to
warranties
(QJOLVK LQVXUDQFH FRQWUDFW ODZ LV FXUUHQWO\ XQGHUJRLQJ D SURFHVV RI
FKDQJH EURXJKW DERXW E\ D SURMHFW WR UHYLHZ DQG ZKHUH QHFHVVDU\
UHIRUPWKHODZEHLQJFRQGXFWHGE\WKH/DZ&RPPLVVLRQVRI(QJODQGDQG
:DOHVDQGRI6FRWODQG7KH&RPPLVVLRQVDUHVWDWXWRU\ERGLHVHQWUXVWHG
ZLWK UHVSRQVLELOLW\ IRU SHULRGLFDOO\ UHYLHZLQJ DQG ZKHUH DSSURSULDWH
UHFRPPHQGLQJUHIRUPRIFLYLOODZLQ*UHDW%ULWDLQ7KHLQVXUDQFHFRQWUDFW
ODZSURMHFWFRPPHQFHGLQ,QWKHPRVWUHFHQWFRQVXOWDWLRQSDSHU
IRUPLQJ SDUW RI LW SXEOLVKHG LQ -XQH WKH /DZ &RPPLVVLRQV KDYH
SURSRVHGWKDWDEUHDFKRIZDUUDQW\VKRXOGRQO\VXVSHQGDQGQRWGLVFKDUJH
WKHLQVXUHU¶VOLDELOLW\DQGWKDWZKHUHDZDUUDQW\LQDSROLF\LVGHVLJQHGWR
UHGXFHWKHULVNRIDSDUWLFXODUW\SHRIORVVWKHLQVXUHU¶VOLDELOLW\VKRXOGEH
VXVSHQGHGRQO\LQUHVSHFWRIDORVVRIWKDWW\SH
7KH SURSRVHG FKDQJH LQ WKH ODZ GRHV QRW KRZHYHU JR TXLWH DV IDU DV
WKH)26DSSURDFKRIUHTXLULQJDFDXVDOOLQNEHWZHHQEUHDFKRIZDUUDQW\
DQG ORVV ,Q WKH H[DPSOH JLYHQ DERYH RI WKH EUHDNLQ WR WKH ¿VK DQG
FKLS VKRS WKH FRXUWV ZRXOG SUREDEO\ GHQ\ WKH LQVXUHG D UHPHG\ HYHQ
0LFKDHO0HQGHORZLW]
XQGHUWKHDPHQGHGZDUUDQW\UHJLPHSURSRVHGE\WKH/DZ&RPPLVVLRQV
RQWKHJURXQGVWKDWWKHORVVRFFXUUHGDVWKHUHVXOWRIDEUHDNLQZKLFK
ZDVSUHFLVHO\WKHVRUWRIULVNZKLFKWKHZDUUDQW\DERXWWKHW\SHRIORFNZDV
LQWHQGHGWRUHGXFH
The future of FOS
7KHZD\LQZKLFKWKH)26RSHUDWHVKDVFKDQJHGRYHUWKH\HDUVDQGFRQWLQXHV
WRFKDQJHLQRUGHUWRHQDEOHWKHRUJDQLVDWLRQWRIXO¿OLWVUHVSRQVLELOLWLHVLQ
WKHPRVWHI¿FLHQWZD\)RUH[DPSOHWKHQXPEHURIFRPSODLQWVZKLFKD
VXEMHFW ¿UP LV HQWLWOHG WR KDYH DGMXGLFDWHG ZLWKRXW FKDUJH ZDV UHFHQWO\
UDLVHGIURPWKUHHWRLQRUGHUDPRQJVWRWKHUIDFWRUVWRHQFRXUDJHWKH
XVHRI)26VHUYLFHV2QWKHRWKHUKDQGWKHSUROLIHUDWLRQLQUHFHQW\HDUV
RIFRPSODLQWVDOOHJLQJPLVVHOOLQJRISD\PHQWSURWHFWLRQLQVXUDQFHRU33,
RIWKHQHZFDVHVKDQGOHGE\WKH)26LQUHODWHGWR
WKHVDOHRI33,ZKHUHDVRQO\RIWRWDOFRPSODLQWVZHUHDERXWLQVXUDQFH
RWKHUWKDQ33,KDVFDXVHGWKH)26WRLQWURGXFHDVXSSOHPHQWDU\FDVHIHH
RILQDGGLWLRQWRWKHVWDQGDUGFDVHIHHRIIRU33,PLVVHOOLQJ
FRPSODLQWV±EXWLWLVRQO\FKDUJHGZKHQVXEMHFW¿UPVKDYHPRUHWKDQ
VXFKFRPSODLQWVPDGHDJDLQVWWKHPLQDQ\RQH\HDU
$PHQGPHQWV WR WKH )26 VFKHPH PDGH E\ WKH )LQDQFLDO 6HUYLFHV $FW
LQFOXGH D UHTXLUHPHQW IRU D 0HPRUDQGXP RI 8QGHUVWDQGLQJ WR EH
HQWHUHGLQWREHWZHHQWKH)26DQGWKH)&$ZKHUHE\WKH)26PXVWGLVFORVH
LQIRUPDWLRQ WR WKH )&$ ZKLFK ZRXOG DVVLVW LQ WKH DGYDQFHPHQW RI WKH
)&$¶VRSHUDWLRQDOREMHFWLYHV,QDGGLWLRQRPEXGVPDQGHFLVLRQVEXWQRW
DGMXGLFDWRUYLHZVZLOOEHSXEOLVKHGLQIXOORQWKH)26ZHEVLWH±WKLVKDV
DOUHDG\ FRPH LQWR HIIHFW 7KH HIIHFW RI WKHVH FKDQJHV LV WKDW WKH )26 LV
EHFRPLQJPRUHWKDQDFRPSXOVRU\DOWHUQDWLYHGLVSXWHUHVROXWLRQVFKHPH
LWZLOODOVREHDUHIHUUDODJHQF\IRUWKH)&$¶VVXSHUYLVRU\DQGHQIRUFHPHQW
WHDPV
:KHQ WKHVH SURSRVDOV ZHUH FRQVXOWHG XSRQ UHVSRQGHQWV ZHUH RQ WKH
ZKROH VXSSRUWLYH RI WKH DSSURDFK VR ORQJ DV FRPPHUFLDOO\ VHQVLWLYH
LQIRUPDWLRQZDVSURWHFWHGDQGWKHQDPHVRIHPSOR\HHVDQGVXEMHFW¿UPV
ZHUHQRWGLVFORVHG+RZHYHUPDQ\UHVSRQGHQWVZHUHRIWKHRSLQLRQWKDW
³QDPLQJ DQG VKDPLQJ´ ZRXOG VHH WKH )26 FURVVLQJ WKH OLQH EHWZHHQ
GLVSXWHUHVROXWLRQVHUYLFHDQGUHJXODWRU7KHTXHVWLRQPXVWWKHUHIRUHEH
DVNHGZLOOWKH)26DVVXPHDQHZFRQVXPHUSURWHFWLRQUROHLQIXWXUHWKDW
LVDVVLVWLQJWKH)&$WRNHHSZDWFKRYHULQVXUHUV"$QGLVWKLV±DOEHLWWKLUW\
\HDUVODWHUWKDQ*HRUJH2UZHOOSUHGLFWHG±DQLQVWDQFHRI³%LJ%URWKHU
>ZLOOEH@ZDWFKLQJ\RX´"
*HRUJH2UZHOONineteen Eighty-Four 6HFNHUDQG:DUEXUJ/RQGRQ
La Mediation En Assurances En France1
Anne Pélissier
Professeur à l’Université Montpellier I (France)
Médiateur du groupe MMA
3URIHVVRU $QQH 3pOLVVLHU WHDFKHV LQ YDULRXV DUHDV RI WKH SULYDWH ODZ DW 0RQWSHOOLHU
8QLYHUVLW\)UDQFHDQGLVH[SHUWHVSHFLDOO\LQWKHÀHOGRILQVXUDQFH6KHDFWVDVPHGLDWRU
in insurance disputes and has a large practical experience in the alternative dispute
UHVROXWLRQ6KHLVWKHDXWKRUPDQ\DUWLFOHVDQGERRNV6KHLVWKHVHFUHWDU\RI$,'$)UDQFH
DQGLVDOVRDPHPEHURI$,'$&RQVXPHU3URWHFWLRQDQG'LVSXWH5HVROXWLRQ:RUNLQJ
3DUW\DVZHOODV$,'$&UHGLW,QVXUDQFHDQG6XUHW\:RUNLQJ3DUW\
7UqVW{WOHVDVVXUHXUVRQWHXFRQVFLHQFHGHO¶LQWpUrWG¶pYLWHUOHVUHFRXUV
MXULGLFWLRQQHOV WDQW SRXU OHXU FRW TXH SRXU OHXU LQÀXHQFH QpIDVWH VXU
O¶LPDJH GH OD VRFLpWp G¶DVVXUDQFH $LQVL OD PpGLDWLRQ HQ DVVXUDQFHV HW
O¶XQH GHV SUHPLqUHV PpGLDWLRQV LQVWLWXWLRQQHOOHV TXL D pWp PLVH HQ SODFH
HQ)UDQFH
&¶HVW HQ HIIHW HQ TXH OHV JURXSHPHQWV G¶DVVXUDQFH )pGpUDWLRQ
)UDQoDLVHGHVVRFLpWpVG¶DVVXUDQFHV±))6$HW*URXSHPHQWGHVHQWUHSULVHV
G¶DVVXUDQFHV ± *(0$ VH VRQW GRWpV G¶XQH &KDUWH GH OD PpGLDWLRQ D¿Q
GH SRVHU OHV UqJOHV GH EDVH GH O¶XWLOLVDWLRQ GH OD PpGLDWLRQ HQ PDWLqUH
G¶DVVXUDQFHHWG¶HQFRXUDJHUOHVSDUWLHVj\UHFRXULUSOXW{WTXHGHVHWRXUQHU
YHUV OD YRLH MXGLFLDLUH 7RXV OHV DVVXUHXUV PHPEUHV GH FHV JURXSHPHQWV
F¶HVWjGLUHODTXDVLWRWDOLWpGHVDVVXUHXUVIUDQoDLVFHVRQWDLQVLHQJDJpV
jUHFRXULUjXQPpGLDWHXUSRXUOHUqJOHPHQWDPLDEOHGHVUpFODPDWLRQVGHV
DVVXUpV 3DU OD VXLWH LOV RQW pWp VXLYLV SDU OD )pGpUDWLRQ 1DWLRQDOHV GH OD
0XWXDOLWp)UDQoDLVH)10)jFRPSWHUGHSDUOD&KDPEUHV\QGLFDOH
GHV FRXUWLHUV HQ DVVXUDQFHV &6&$ j FRPSWHU GH SDU OH &HQWUH
7HFKQLTXHGHV,QVWLWXWLRQVGHSUpYR\DQFH&7,3jFRPSWHUGHPDUV
$¿QGHPHVXUHUO¶DYDQFpHGHVDVVXUHXUVIUDQoDLVHQODPDWLqUHRQSHXW
pJDOHPHQWPHQWLRQQHUTXHO¶H[LVWHQFHG¶XQPpGLDWHXUHQPDWLqUHEDQFDLUH
Q¶HVWREOLJDWRLUHTXHGHSXLV/RLGXGpFHPEUHDUW/
GX&RGHPRQpWDLUHHW¿QDQFLHU
&HTXLHVWUHPDUTXDEOHHQDVVXUDQFHF¶HVWTXHFHVDYDQFpHVGHVPRGHV
1
,OHVWSUpFLVpTXHWRXWHVOHVVWDWLVWLTXHVFLWpHVVRQWLVVXHVGXUDSSRUWDQQXHOGXPpGLDWHXU
GH OD ))6$ SUpVHQWDQW GHV FKLIIUHV UHJURXSDQW WRXV OHV PpGLDWHXUV HQ DVVXUDQFHV
FRQVXOWDEOHVXUZZZIIVDIU
Anne Pélissier
H[WUDMXGLFLDLUHVGHUqJOHPHQWGHVOLWLJHV5(/FRPPHLOVVRQWQRPPpVHQ
GURLWGHO¶8QLRQHXURSpHQQHRQWpWpREWHQXHVSDUODYRLHFRQYHQWLRQQHOOH
OHV DVVXUHXUV VH VRXPHWWDQW YRORQWDLUHPHQW SDU OH ELDLV GH FRQYHQWLRQV
FRQFOXHV DX QLYHDX GHV GHX[ IpGpUDWLRQV SURIHVVLRQQHOOHV OD ))6$ SRXU
OHV VRFLpWpV DQRQ\PHV G¶DVVXUDQFH HW OHV VRFLpWp G¶DVVXUDQFH PXWXHOOH
GLVWULEXDQW OHXUV SURGXLWV SDU OH ELDLV G¶XQ UpVHDX G¶LQWHUPpGLDLUHV HW OH
*(0$SRXUOHVVRFLpWpG¶DVVXUDQFHPXWXHOOHGLVWULEXDQWGLUHFWHPHQWOHXUV
SURGXLWV
/H OpJLVODWHXU Q¶HVW LQWHUYHQX TX¶HQ VHFRQGH PDLQ HQ YHQDQW LPSRVHU
XQHREOLJDWLRQG¶LQIRUPDWLRQGHVDVVXUpVjO¶pJDUGGXWUDLWHPHQWGHOHXUV
UpFODPDWLRQV REOLJDWLRQ SUpVXSSRVDQW OD UHFRQQDLVVDQFH LPSOLFLWH GX
GLVSRVLWLI GH PpGLDWLRQ PLV HQ SODFH j O¶LQLWLDWLYH GHV DVVXUDQFHV /D ORL
Q GX MDQYLHU HVW YHQXHDMRXWHUj O¶DUWLFOH /DOLQpD GX&RGHGHVDVVXUDQFHVUHODWLIDXIRUPDOLVPHLQIRUPDWLISUpFRQWUDFWXHO
O¶H[LJHQFH GH O¶LQGLFDWLRQ GDQV OHV GRFXPHQWV UHPLV j O¶DVVXUp GHV
« modalités d’examen des réclamations qu’il peut formuler au sujet du
contrat, y compris, le cas échéant, l’existence d’une instance chargée en
particulier de cet examen, sans préjudice pour lui d’intenter une action
en justice » /HV DVVXUHXUV RQW GRQF O¶REOLJDWLRQ G¶LQIRUPHU OHV DVVXUpV
VXUO¶H[LVWHQFHG¶XQSURFHVVXVGHWUDLWHPHQWDPLDEOHGHVUpFODPDWLRQVGHV
DVVXUpVPDLVOHXUVRXPLVVLRQjFHGLVSRVLWLIQ¶HVWSDVLPSRVpHSDUODORL
PDLVSDUODYRLHFRQYHQWLRQQHOOH
6L O¶LQWHQWLRQ GHV DVVXUHXUV HVW ERQQH HW OHV UpVXOWDWV HQFRXUDJHDQWV
O¶$XWRULWp GH &RQWU{OH 3UXGHQWLHO HW GH 5pVROXWLRQ $&35 DXWRULWp GH
FRQWU{OHFRPPXQHDX[VHFWHXUVGHO¶DVVXUDQFHHWGHODEDQTXHHQ)UDQFH
DFRQVWDWpTXHOHGLVSRVLWLISRXYDLWrWUHDPpOLRUpHQ\LQVXIÀDQWGDYDQWDJH
GHWUDQVSDUHQFHHWHQKDUPRQLVDQWOHVSUDWLTXHVTXLDYDLHQWWHQGDQFHj
rWUHDVVH]KpWpURJqQHVHQWUHOHVGLIIpUHQWHVVRFLpWpVG¶DVVXUDQFHWDQWOD
&KDUWHGHODPpGLDWLRQOHXURIIUDLWGHOLEHUWp$FHWHIIHWO¶$&35DIRUPXOp
XQH UHFRPPDQGDWLRQ VXU OH WUDLWHPHQW GHV UpFODPDWLRQV HQ GDWH GX GpFHPEUH TXL D HQJDJp OHV DVVXUHXUV j SDUIDLUH OH V\VWqPH GH
UqJOHPHQW DPLDEOH GHV GLIIpUHQGV &¶HVW FH GLVSRVLWLI UpQRYp TXH QRXV
DOORQVGpFULUHHQUpSRQGDQWjGLIIpUHQWHVTXHVWLRQV
1) Quel est le périmètre de la médiation?
/DPpGLDWLRQWHOOHTX¶HOOHUpVXOWHGHV&KDUWHVGHODPpGLDWLRQQ¶HVWSUpYXH
TXHSRXUOHVOLWLJHVRSSRVDQWXQSDUWLFXOLHUjXQHVRFLpWpG¶DVVXUDQFHQpV
jO¶RFFDVLRQGXFRQWUDWG¶DVVXUDQFH'qVORUVODPpGLDWLRQHVWOLPLWpHDX[
FRQWUDWVG¶DVVXUDQFHFRQFOXVGDQVOHFDGUHGHODYLHSULYpHOHVULVTXHV
SURIHVVLRQQHOVHQVRQWHQSULQFLSHH[FOXV
/D0HGLDWLRQ(Q$VVXUDQFHV(Q)UDQFH
/DIRUPXODWLRQGXSpULPqWUHGHODPpGLDWLRQHVWYRORQWDLUHPHQWODUJHPDLV
HOOHQHYDSDVVDQVSRVHUGHGLI¿FXOWpVGHIURQWLqUHV$LQVLVLOHPpGLDWHXU
HVWFRPSpWHQWSRXUOHVSUREOqPHVMXULGLTXHVGpFRXODQWGXOLHQFRQWUDFWXHO
LO VHUD LQFRPSpWHQW GX PRLQV WHFKQLTXHPHQW VL FH VRQW OHV FRQFOXVLRQV
G¶XQ H[SHUW TXL VRQW FRQWHVWpHV (JDOHPHQW V¶DJLVVDQW GH WDUL¿FDWLRQ
OH PpGLDWHXU QH VHUD SDV FRPSpWHQW SRXU VWDWXHU VXU OHV PRGDOLWpV GH
SDLHPHQWGHVSULPHVTXLQ¶LQFRPEHQWTX¶jODFRPSDJQLH2XHQFRUHLOQH
OXLDSSDUWLHQWSDVGHGpFLGHUG¶XQJHVWHFRPPHUFLDO,OSHXW\HQFRXUDJHU
PDLVFHUWHVSDVO¶LPSRVHU
2) Qui est le médiateur?
/DUpSRQVHjFHWWHTXHVWLRQHVWDVVH]GpOLFDWHSXLVTXHjFHMRXULOQ¶\DSDV
XQPpGLDWHXUHQDVVXUDQFHVPDLVQHXIPpGLDWHXUV'HX[PpGLDWHXUVVRQW
GLWV©SURIHVVLRQQHOVªFDULOVVRQWUDWWDFKpVDX[IpGpUDWLRQVSURIHVVLRQQHOOHV
TXHVRQWOD))6$HWOH*(0$3RXUWRXWHVOHVHQWUHSULVHVUHOHYDQWGX*(0$
VHXOOHPpGLDWHXUSURIHVVLRQQHOHVWDSSHOpjLQWHUYHQLU,OHVWGRQFXQLTXH
(Q UHYDQFKH SRXU OHV HQWUHSULVHV UHOHYDQW GH OD ))6$ OD &KDUWH GH OD
PpGLDWLRQDSUpYXTXHOHVHQWUHSULVHVTXLOHVRXKDLWHQWSRXYHQWIDLUHDSSHO
jXQPpGLDWHXUGHOHXUFKRL['DQVODPHVXUHRFHPpGLDWHXUHVWGpVLJQp
SDUO¶HQWUHSULVHRXXQJURXSHG¶HQWUHSULVHVHWTX¶LOHVWDSSHOpjQHFRQQDvWUH
TXHGHVUpFODPDWLRQVSRUWDQWVXUGHVFRQWUDWVGLVWULEXpVSDUFHWWHHQWUHSULVH
FHPpGLDWHXUHVWLPSURSUHPHQWGpQRPPp©PpGLDWHXUG¶HQWUHSULVHªPDLV
LO UHVWH LQGpSHQGDQW HW H[WpULHXU j O¶HQWUHSULVH 6HSW HQWUHSULVHV RQW IDLW
FH FKRL[ ,O V¶DJLW G¶$;$ &13 $VVXUDQFHV *0) *5283$0$ *(1(5$/,
00$HW1(8)/,=(9LH/¶DYDQWDJHGHUHFRXULUjXQPpGLDWHXULQGpSHQGDQW
HVWSRXUFHVVRFLpWpVG¶DVVXUDQFHQRQVHXOHPHQWGHSRXYRLUGpWHUPLQHU
OHGRPDLQHTX¶HOOHVHQWHQGHQWGRQQHUjODPpGLDWLRQ00$DSDUH[HPSOH
pODUJLODPpGLDWLRQDX[ULVTXHVSURIHVVLRQQHOVPDLVpJDOHPHQWGHSRXYRLU
DYRLUXQHJHVWLRQSOXVVHUUpHHWSOXVSUpFLVHGHVUpFODPDWLRQVHWQRWDPPHQW
GHVTXHVWLRQVMXULGLTXHVUpFXUUHQWHVTXLUHPRQWHQWDXPpGLDWHXUFHTXL
SHUPHWIDLUHpYROXHUSOXVDLVpPHQWOHVFRQWUDWVHWOHVSUDWLTXHVDXVHLQGH
O¶HQWUHSULVH
&RPPH LO SHXW rWUH GLI¿FLOH SRXU O¶DVVXUp GH FRQQDvWUH SUpFLVpPHQW OH
PpGLDWHXUDXTXHOLOGRLWV¶DGUHVVHUSOXVLHXUVLQLWLDWLYHVRQWpWpPLVHVHQ
SODFH 7RXW G¶DERUG XQH ERvWH SRVWDOH 0(',$7,21 $6685$1&( UXH
-XOHV /HIHEYUH 3$5,6 FHGH[ LQGLTXH j O¶DVVXUp VXU VLPSOH
GHPDQGH OHV FRRUGRQQpHV GX PpGLDWHXU GRQW LO GpSHQG (QVXLWH O¶$&35
SDU OH ELDLV G¶XQH SODWHIRUPH WpOpSKRQLTXH UpRULHQWH OHV UpFODPDQWV VXU
OHVGLIIpUHQWVPpGLDWHXUV(Q¿QGHSXLVODUHFRPPDQGDWLRQGHO¶$&35OD
VRFLpWpG¶DVVXUDQFHTXLRSSRVHXQUHIXVjXQHUpFODPDWLRQPHQWLRQQHGDQV
FHFRXUULHUOHSRVVLEOHDFFqVHWOHVFRRUGRQQpHVGXPpGLDWHXU
Anne Pélissier
4XDQWjODSHUVRQQHGXPpGLDWHXULOV¶DJLWG¶XQHSHUVRQQDOLWpLQGpSHQGDQWH
FKRLVLHSRXUVHVFRPSpWHQFHVHQPDWLqUHG¶DVVXUDQFHHWSOXVSUpFLVpPHQW
HQ GURLW GHV DVVXUDQFHV DQFLHQ GLUHFWHXU GH FRPSDJQLH G¶DVVXUDQFH
SURIHVVHXUGHGURLWDQFLHQPDJLVWUDW«
3) Comment saisit-on le médiateur?
/D VDLVLQH GX PpGLDWHXU UHSRVH VXU OD IRUPXODWLRQ SDU O¶DVVXUp G¶XQH
UpFODPDWLRQ /D Gp¿QLWLRQ GRQQpH SDU O¶8QLRQ HXURSpHQQH GDQV XQH
UHFRPPDQGDWLRQ GX PDL UHODWLYH j O¶XWLOLVDWLRQ G¶XQH PpWKRGH
harmonisée pour classer les réclamations est on ne peut plus large : « une
déclaration actant le mécontentement exprimé par un consommateur envers
un professionnel » /H PpFRQWHQWHPHQW GX SDUWLFXOLHU FRQVWLWXH OH JHUPH
GXOLWLJH/¶DSSUpKHQVLRQHVWYRORQWDLUHPHQWDFFXHLOODQWHGHIDoRQjQHSDV
ODLVVHUV¶HQOLVHUOHPpFRQWHQWHPHQWMXVTX¶jFHTX¶LOGpJpQqUHHQFRQÀLW
a) Conditions de saisine
,O Q¶\ D TXH GHX[ FRQGLWLRQV j OD VDLVLQH GX PpGLDWHXU TXH WRXWHV OHV
YRLHVGHUHFRXUVLQWHUQHVjO¶HQWUHSULVHG¶DVVXUDQFHDLHQWpWppSXLVpHVHW
TX¶DXFXQHDFWLRQHQMXVWLFHQHVRLWGLOLJHQWpH
/D PpGLDWLRQ HQ DVVXUDQFHV Q¶HVW HQ HIIHW TXH OH VHFRQG QLYHDX GX
WUDLWHPHQWDPLDEOHGHVUpFODPDWLRQV
Au 1er niveau OD UpFODPDWLRQ HVW SRUWpH GHYDQW XQ VHUYLFH LQWHUQH j OD
FRPSDJQLH G¶DVVXUDQFH OD WHUPLQRORJLH YDULH VHUYLFH UpFODPDWLRQV
FOLHQWVVHUYLFHTXDOLWpVHUYLFHFRQVRPPDWHXUV«TXLHVWLQGpSHQGDQWGHV
VHUYLFHVGHJHVWLRQGHODVRFLpWp/HGRVVLHUHVWUpH[DPLQpSDUOHVHUYLFH
UpFODPDWLRQTXLYpUL¿HO¶RSSRUWXQLWpGHODSRVLWLRQGXVHUYLFHGHJHVWLRQ
&H VHUYLFH YD WHQWHU GH UpDOLVHU XQH FRQFLOLDWLRQ HQ LQWHUQH GH IDoRQ j
YLGHU OH FRQWHQWLHX[ 6L OH GLIIpUHQG SHUVLVWH HW TXH WRXWHV OHV YRLHV GH
UHFRXUVLQWHUQHVVRQWpSXLVpHVOHUpFODPDQWSRXUUDGHPDQGHUODVDLVLQH
GXPpGLDWHXU
Au 2QG niveauOHUpFODPDQWDODSRVVLELOLWpGHVROOLFLWHUO¶DYLVGXPpGLDWHXU
,O V¶DJLW PrPH G¶XQ GURLW j OD PpGLDWLRQ DXTXHO VH VRQW HQJDJpHV OHV
FRPSDJQLHVG¶DVVXUDQFHGDQVOD&KDUWHGHODPpGLDWLRQ
/H PpGLDWHXU SHXW DORUV rWUH VDLVL SDU O¶DVVXUp SDU OD VRFLpWp
G¶DVVXUDQFHRXH[FOXVLYHPHQWSRXUODFKDUWHGHODPpGLDWLRQGH
OD))6$SDUWRXWWLHUVLQWpUHVVpDVVRFLDWLRQVGHFRQVRPPDWHXUV
DYRFDWVHQWRXUDJHGHO¶DVVXUp«
,OIDXWHQFRUHSUpFLVHUTXHODVDLVLQHGXPpGLDWHXUHVWWRWDOHPHQWJUDWXLWH
SRXUOHVDVVXUpVOHVHQWUHSULVHVG¶DVVXUDQFHOHSUHQDQWjOHXUFKDUJH
/D0HGLDWLRQ(Q$VVXUDQFHV(Q)UDQFH
(QDSSOLFDWLRQGHFHGLVSRVLWLIHQGHPDQGHVGHVDLVLQHRQW
pWp SRUWpHV GHYDQW OHV PpGLDWHXUV 6XU FHWWH PDVVH VHXOV GHV
GRVVLHUVVDWLVIDLVDLHQWjODGRXEOHFRQGLWLRQGHVDLVLQHHWRQWpWpDFFHSWpV
HQPpGLDWLRQ/HVDXWUHVRQWpWpUHQYR\pVHQSURFpGXUHLQWHUQHRX
GpFODUpVKRUVSpULPqWUH
2QUHOqYHUDTXHOHQRPEUHGHGHPDQGHVGHVDLVLQHpWDLWGHHQ
HQHQHWHQ&¶HVWGLUHVLOHVFKLIIUHVRQW
H[SORVpGHSXLVODPLVHHQSODFHGXGLVSRVLWLI
b) Effet de la saisine
'HSXLVODORLGXMXLQUpIRUPDQWOHGURLWIUDQoDLVGHODSUHVFULSWLRQ
OH QRXYHO DUWLFOH GX &RGH FLYLO SUpYRLW TXH OD VDLVLQH GX PpGLDWHXU
VXVSHQGODSUHVFULSWLRQGHO¶DFWLRQHQMXVWLFH/HFRXUVGHODSUHVFULSWLRQ
HVWGRQFDUUrWpGqVODVDLVLQHSRXUUHSUHQGUHOjRLOHQpWDLWUHVWpXQHIRLV
O¶DYLVUHQGXSRXUXQHGXUpHTXLQHSHXWrWUHLQIpULHXUHjVL[PRLV
4) Quel est la mission du médiateur?
,OQHIDXWSDVVHPpSUHQGUHODPpGLDWLRQHQDVVXUDQFHQ¶DTXHWUqVSHXGH
FKRVHVHQFRPPXQDYHFOHVPpGLDWLRQVMXGLFLDLUHHWFRQYHQWLRQQHOOH(OOH
IRQFWLRQQHHQUHYDQFKHFRPPHEHDXFRXSGHPpGLDWLRQVLQVWLWXWLRQQHOOHV
(QDVVXUDQFHLOV¶DJLWG¶XQHPpGLDWLRQVXUSLqFHVGRQFKRUVODSUpVHQFH
GHVSDUWLHV,OQHV¶DJLWGRQFSDVG¶DLGHUOHVSDUWLHVjFRPPXQLTXHUD¿Q
TX¶HOOHVSDUYLHQQHQWHOOHVPrPHVjWURXYHUXQHVROXWLRQjOHXUOLWLJHPDLV
XQLTXHPHQW GH SURSRVHU XQH VROXWLRQ DX OLWLJH TXL VHPEOH DGDSWpH DX
PpGLDWHXU
/HPpGLDWHXUGRLWDLQVLUHQGUHXQDYLVVXUO¶LVVXHGXOLWLJH$FHWHIIHWLOSHXW
VHIRQGHUVXUOHGURLWHWRXVXUO¶pTXLWp/HU{OHGXPpGLDWHXUHQDVVXUDQFHV
HVWDLQVLSOXVSURFKHGHFHOXLG¶XQMXJHGHO¶DPLDEOHTXLQ¶DSDVGHSRXYRLU
GHFRHUFLWLRQPDLVTXLSURSRVHXQHVROXWLRQTXLWUDQFKHOHGLIIpUHQGTXH
G¶XQPpGLDWHXUMXGLFLDLUHRXFRQYHQWLRQQHO
3RXU DFFRPSOLU FHWWH PLVVLRQ OHV PpGLDWHXUV UHOHYDQW GH OD FKDUWH GH
OD ))6$ GLVSRVHQW GH WURLV PRLV j FRPSWHU GH OHXU VDLVLQH WDQGLV TXH OH
PpGLDWHXUGX*(0$DVL[PRLVSRXUUHQGUHVRQDYLV
,OIDXWQRWHUTXHODPpGLDWLRQHVWLQWHUURPSXHVLXQHDFWLRQHVWSRUWpHHQ
MXVWLFH
5) Quelle est l’autorité des avis du médiateur?
$ O¶pJDUG GHV DVVXUpV RX GHV WLHUV O¶DYLV Q¶D DXFXQH IRUFH REOLJDWRLUH
/¶DVVXUpRXOHWLHUVGLVSRVHQWWRXMRXUVGXGURLWG¶DJLUHQMXVWLFHFHTXLOHXU
HVWG¶DLOOHXUVUDSSHOpSDUOHPpGLDWHXUORUVTX¶LOUHQGVRQDYLV
Anne Pélissier
$ O¶pJDUG GHV DVVXUHXUV OHV DYLV GX PpGLDWHXUV GX *(0$ RQW IRUFH
REOLJDWRLUH&HQ¶HVWSDVOHFDVSRXUOHVPpGLDWHXUVREpLVVDQWjOD&KDUWH
GHOD))6$GRQWO¶DYLVQ¶HVWTXHFRQVXOWDWLI7RXWHIRLVHQSUDWLTXHFHWDYLV
HVWVXLYLHQWUHHWGHVFDV
/HV VWDWLVWLTXHV PRQWUHQW TXH VXU OHV DYLV UHQGXV HQ VRQWIDYRUDEOHVDX[UpFODPDQWVOHXUVVRQWSDUWLHOOHPHQWIDYRUDEOHV
HWGRQFOHXUVVRQWGpIDYRUDEOHVOHVVWDWLVWLTXHVVRQWjSHXSUqV
VLPLODLUHV G¶XQH DQQpH VXU O¶DXWUH &HV FKLIIUHV V¶H[SOLTXHQW SDU OHV
GHX[pWDSHVGXGLVSRVLWLI6LODFRQFLOLDWLRQHVWHQYLVDJHDEOHO¶HQWUHSULVH
G¶DVVXUDQFHFRPSWHWHQXGXFRWHQJHQGUpSDUODPpGLDWLRQSUpIqUHUpJOHU
Gp¿QLWLYHPHQWOHGLIIpUHQGHQLQWHUQH3DUFRQVpTXHQWVHXOVOHVGRVVLHUV
RODFRPSDJQLHHVWVUHGHVDSRVLWLRQSDUYLHQQHQWDXPpGLDWHXU
(Q FRQFOXVLRQ GH FHWWH SUpVHQWDWLRQ LO FRQYLHQW GH PHQWLRQQHU O¶LPSDFW
GpWHUPLQDQWTXHYDDYRLUODGLUHFWLYH8(GXPDLUHODWLYH
DXUqJOHPHQWH[WUDMXGLFLDLUHGHVOLWLJHVGHFRQVRPPDWLRQVXUOHV\VWqPHGH
PpGLDWLRQHQDVVXUDQFHVTXLGRLWrWUHWUDQVSRVpHGDQVOHV(WDWVPHPEUHV
GHO¶8QLRQHXURSpHQQHDYDQWOHMXLOOHW
&HWWH GLUHFWLYH SUpYRLW TXH FKDTXH (WDW PHPEUH GHYUD GpVLJQHU XQH
RX SOXVLHXUV DXWRULWpV TXL DXURQW SRXU PLVVLRQ GH GUHVVHU XQH OLVWH GHV
HQWLWpVGH5(/UHFRQQXHVFRPPHREpLVVDQWDX[FULWqUHVG¶LQGpSHQGDQFH
G¶LPSDUWLDOLWpGHWUDQVSDUHQFHG¶HI¿FDFLWpGHUDSLGLWpHWG¶pTXLWpSRVpVSDU
ODGLUHFWLYH'qVORUVGDQVODPHVXUHRODUHFRQQDLVVDQFHFRPPHHQWLWpGH
5(/GpSHQGUDGHODYRORQWpGHO¶DXWRULWpQRPPpHSDUO¶(WDWPHPEUHFHOD
QHSHUPHWSDVGHVDYRLUjFHMRXUVLFHWWHDXWRULWpVRXKDLWHUDPDLQWHQLU
OHV\VWqPHGHPpGLDWLRQHQDVVXUDQFHVWHOTXHQRXVO¶DYRQVGpFULWRXVL
HOOHSUpIpUHUDOLPLWHUOHQRPEUHGHPpGLDWHXUjGHX[))6$HW*(0$jXQ
SRXUWRXWOHVHFWHXUGHO¶DVVXUDQFHYRLUHjXQXQLTXHPpGLDWHXUSRXUOHV
VHFWHXUVEDQTXHHWDVVXUDQFH(QRXWUHVLXQRXSOXVLHXUVPpGLDWHXUVHQ
DVVXUDQFHVVRQWUHFRQQXVGHVPRGL¿FDWLRQVGHYURQWrWUHDSSRUWpHVGDQV
OHXU PRGH GH IRQFWLRQQHPHQW WHOOHV TXH XQH GpVLJQDWLRQ j SDULWp SDU
GHV DVVXUHXUVHW GHV DVVXUpV XQ EXGJHW SURSUH XQ VLWH LQWHUQHW SURSUH
DX PpGLDWHXU SHUPHWWDQW GH UHFXHLOOLU OHV GRVVLHUV GH UpFODPDWLRQV« 'H
SURIRQGV ERXOHYHUVHPHQWV DWWHQGHQW DLQVL OD PpGLDWLRQ HQ DVVXUDQFHV j
WUqVFRXUWWHUPH,OUHVWHjHVSpUHUTXHFHVHUDSRXUOHSOXVJUDQGSUR¿W
GHVDVVXUpVHWSDVDXGpWULPHQWG¶XQV\VWqPHTXLIRQFWLRQQHELHQHWTXLD
IDLWVHVSUHXYHV
Alternative Dispute Resolution
Sweden
Rose-Marie Lundström
Rose-Marie Lundström Advokat AB
Rose-Marie Lundström has a broad and strong insurance and reinsurance legal experience,
including a deep understanding of the insurance industry, as inhouse lawyer of Skandia
,QVXUDQFH &RPSDQ\ ² DQG FDVXDOW\ FODLPV PDQDJHU ² DQG DV
LQKRXVHODZ\HUDQGYLFHSUHVLGHQWRI6NDQGLD,QWHUQDWLRQDO²6KHKDVEHHQ
LQSULYDWHSUDFWLFHVLQFHDQGLVQRZSULQFLSDORI5RVH0DULH/XQGVWU|P$GYRNDW
$%6WRFNKROP
Rose-Marie has arbitrated and litigated a range of substantial insurance and reinsurance
disputes. She also acts as an arbitrator in insurance and reinsurance matters. Her practice
and experience includes a variety of legal areas such as casualty, professional liability,
product liability, environmental liability, personal injuries, accident and health, property
and regulatory matters. In addition she has experience advising on insurance/reinsurance
wordings, on coverage and construction issues. She is a lecturer of insurance and
reinsurance law at the Universities of Uppsala and Stockholm. She is Vice Chairman of
WKH6ZHGLVK1DWLRQDO&ODLPV$GMXVWPHQW%RDUG6KHLVDPHPEHURIWKHH[SHUWSDQHORQ
Insurance Law at Stockholm Centre for Commercial Law and a member of the Swedish
%DU $VVRFLDWLRQ·V $GYLVRU\ %RDUG RQ ,QVXUDQFH LQ SDUWLFXODU SURIHVVLRQDO LQGHPQLW\
insurance). She serves in the ICC Reference Group on Financial Services and Insurance.
6KH LV &KDLUPDQ RI WKH 6ZHGLVK &KDSWHU RI $,'$ $VVRFLDWLRQ RI ,QVXUDQFH /DZ
$VVRFLDWLRQ ,QWHUQDWLRQDOH GH 'URLW GHV $VVXUDQFHV PHPEHU RI $,'$·V 3UHVLGHQWLDO
&RXQFLODQG3DQHO0HPEHU5HLQVXUDQFH:RUNLQJ3DUW\RI$,'$
Introduction
6ZHGHQ KDV D ORQJ WUDGLWLRQ RI VROYLQJ LQVXUDQFH UHODWHG GLVSXWHV RXW RI
FRXUW7KHDGYDQWDJHVDUHREYLRXVLWLVTXLFNHUDQGFKHDSHU7KHPDMRU
GLVDGYDQWDJH LV RI FRXUVH WKH UHVXOWLQJ VFDUFLW\ RI FRXUW SUHFHGHQWV DQG
WKHUHE\DODFNRIJXLGDQFHZKLFKSURYHVSUREOHPDWLFLQPDQ\LQVWDQFHV
7KHUHDUHDQXPEHURIGLVSXWHUHVXOWLRQIDFLOLWLHVRIGLIIHUHQWFKDUDFWHUDQG
VL]HIRUGLIIHUHQWNLQGVRIGLVSXWHV$EULHIRYHUYLHZLVJLYHQEHORZ
1. The National Board for Consumer Complaints (Sw.:
Allmänna Reklamationsnämnden)
General background
7KH1DWLRQDO%RDUGIRU&RQVXPHU&RPSODLQWV$51LVDSXEOLFDXWKRULW\
5RVH0DULH/XQGVWU|P
$51¶V PDLQ WDVN LV WR LPSDUWLDOO\ WU\ GLVSXWHV EHWZHHQ FRQVXPHUV DQG
EXVLQHVVHV
$51 LV GLYLGHG LQWR WKLUWHHQ GLIIHUHQW GHSDUWPHQWV DPRQJ WKHP DQ
,QVXUDQFH 'HSDUWPHQW 7KH ,QVXUDQFH 'HSDUWPHQW LV SULPDULO\ IRFXVVHG
XSRQLQVXUDQFHSROLFLHVDQGLQWHUSUHWDWLRQ
$51JLYHVQRQELQGLQJUHFRPPHQGDWLRQVRQO\
,QWKH,QVXUDQFH'HSDUWPHQWUHFHLYHGFRPSODLQWVZKLFKPHDQWDQ
LQFUHDVHRIFRPSDUHGWR,QJHQHUDORI$51¶VGHFLVLRQVZHUH
DFFHSWHGDQGIROORZHGE\EXVLQHVVRSHUDWRUVZKLOVWUHFRPPHQGDWLRQVPDGH
E\WKH,QVXUDQFH'HSDUWPHQWZHUHDFFHSWHGDQGIROORZHG
Cross-border disputes
$51LVWKHFRPSHWHQWDXWKRULW\WRWU\GLVSXWHVEHWZHHQFRQVXPHUVLQRWKHU
(8FRXQWULHVDQGLQVXUDQFHFRPSDQLHVLQ6ZHGHQ
6ZHGLVKFRQVXPHUVZKRKDYHDFRQÀLFWZLWKLQVXUDQFHFRPSDQLHVLQRWKHU
FRXQWULHVZLWKLQWKH(8FDQWXUQWRWKHLU(XURSHDQ&RQVXPHU&HQWUHIRU
DGYLFHDQGDVVLVWDQFH7KH6ZHGLVK(XURSHDQ&RQVXPHU&HQWUHLVFDOOHG
Konsument Europa
The Procedure
&ODLPVDUH¿OHGE\FRQVXPHUVSROLF\KROGHUV$FODLPWR$51PXVWEHPDGH
ZLWKLQ VL[ PRQWKV IURP WKH SRLQW RI WLPH ZKHQ WKH LQVXUDQFH FRPSDQ\
UHMHFWVDFODLPSDUWLDOO\RUZKROO\
*URXS$FWLRQVDUHDOORZHG
$FODLPPXVWH[FHHGD¿[HGDPRXQW7KHOLPLWWKDWDSSOLHVLQUHVSHFWRI
PDWWHUV WKDW IDOO XQGHU $51¶V ,QVXUDQFH 'HSDUWPHQW LV DW SUHVHQW 6(.,QFDVHDGLVSXWHLVRIDSULQFLSOHQDWXUHRULIWKHUHDUHRWKHUVSHFLDO
FLUFXPVWDQFHV$51FDQFKRRVHWRWU\WKHGLVSXWHGHVSLWHWKHIDFWWKDWWKH
FODLPLVEHORZWKHVWLSXODWHGOLPLWRI6(.
Contracts entered into in Sweden
1RUPDOO\$51¶VLQTXLU\LVOLPLWHGWRFRQWUDFWVWKDWKDYHEHHQHQWHUHGLQWR
LQ6ZHGHQ
Types of matters that ARN does not try
GLVSXWHVEHWZHHQSULYDWHSHUVRQVRUEHWZHHQEXVLQHVVHV
GLVSXWHVZKHUHDPHGLFDODVVHVVPHQWLVQHHGHG
GLVSXWHVFRQFHUQLQJOHJDOVHUYLFHV
GLVSXWHVWKDWKDYHEHHQVXEPLWWHGWRFRXUWIRUWULDO
GLVSXWHVZKHUHWKHEXVLQHVVRSHUDWRUKDVHQWHUHGEDQNUXSWF\
$OWHUQDWLYH'LVSXWH5HVROXWLRQ6ZHGHQ
$51 PD\ DOVR UHMHFW PDWWHUV WKDW GXH WR $51¶V ZULWWHQ SURFHGXUHV DQG
VLPSOL¿HG ZRUNLQJ PHWKRGV FDQQRW EH VDWLVIDFWRULO\ LQYHVWLJDWHG RU
RWKHUZLVHDUHQRWDSSURSULDWHWR$51¶VLQTXLU\
How a dispute is settled
$GHSDUWPHQWFRQVLVWVRIDFKDLUSHUVRQDYLFHFKDLUSHUVRQDQGIRXURWKHU
PHPEHUV 7KH FKDLUSHUVRQ LV D ODZ\HU ZLWK FRXUW H[SHULHQFH 7KH RWKHU
PHPEHUVFRPHIURPFRQVXPHUDQGWUDGHRUJDQLVDWLRQV
$GHSDUWPHQWFRQVWLWXWHVDTXRUXPLHLVFRPSHWHQWWRPDNHDGHFLVLRQ
ZKHQWKHFKDLUSHUVRQDQGIRXURWKHUPHPEHUVDUHSUHVHQW
2FFDVLRQDOO\ LQFRQVLVWHQW RSLQLRQV KDYH EHHQ JLYHQ E\ $51 RQ WKH
LQWHUSUHWDWLRQRILGHQWLFDOSROLF\ZRUGLQJV7KHUHDUHDWOHDVWWZRH[DPSOHV
ZKHUHWKH6ZHGLVK6XSUHPH&RXUWKDYHJUDQWHGOHDYHRIDSSHDOLQRUGHUWR
SURYLGHJXLGDQFHWKURXJKDXWKRULWDWLYHOHJDOSUHFHGHQWV1-$S
DQG 1-$ S %RWK FDVHV FRQFHUQHG 7KHIW ,QVXUDQFH IRU PRWRU
ELNHV
7KH5RDG7UDI¿F,QMXULHV&RPPLVVLRQ6Z
7UD¿NVNDGHQlPQGHQ
General background
7KH 5RDG 7UDI¿F ,QMXULHV &RPPLVVLRQ ZDV HVWDEOLVKHG LQ 7KH
&RPPLVVLRQ LV UHJXODWHG E\ WKH 7UDI¿F ,QVXUDQFH 2UGLQDQFH Sw WUD¿NI|UVlNULQJVI|URUGQLQJHQ $OO LQVXUDQFH FRPSDQLHV ZKLFK
SURYLGHWUDI¿FLQVXUDQFHDUHXQGHUDQREOLJDWLRQWRPDLQWDLQDQG¿QDQFH
WKH&RPPLVVLRQ7KH&RPPLVVLRQ¶V5HJXODWLRQVVKDOOEHDSSURYHGE\WKH
*RYHUQPHQW 7KLV PHDQV RI FRXUVH DOVR WKDW WKH UHJXODWLRQV FDQQRW EH
FKDQJHGZLWKRXW*RYHUQPHQWDSSURYDO
7KH RYHUULGLQJ SXUSRVH LV WR DFKLHYH D XQLWDU\ DQG IDLU FODLPV KDQGOLQJ
ZLWKLQWKHWUDI¿FLQVXUDQFH
8QGHU6ZHGLVKODZDOOPRWRUYHKLFOHVPXVWEHLQVXUHG$FFRUGLQJWRWKH
7UDI¿F'DPDJHV$FWSw7UD¿NVNDGHODJHQZKLFKFDPHLQWRIRUFHLQ
DOOYLFWLPVRIWUDI¿FDFFLGHQWV±GULYHUVSDVVHQJHUVDVZHOODVSHGHVWULDQV
DQG F\FOLVWV DUH HQWLWOHG WR UHFHLYH LQ SULQFLSOH IXOO FRPSHQVDWLRQ IRU
SHUVRQDOLQMXULHVVXIIHUHG
8QLQVXUHGRUXQLGHQWL¿HGPRWRUYHKLFOHV
,Q FDVHV ZKHUH XQLQVXUHG RU XQLGHQWL¿HG PRWRU YHKLFOHV DUH
LQYROYHG FRPSHQVDWLRQ LV SDLG E\ WKH 6ZHGLVK 0RWRU ,QVXUHUV Sw
7UD¿NI|UVlNULQJVI|UHQLQJHQ ´7))´ IRUPHUO\ 0RWRU ,QVXUHUV¶ %XUHDX RI
6ZHGHQ
5RVH0DULH/XQGVWU|P
The Commission’s structure
Chairman
7KH FKDLUPDQ LV DSSRLQWHG E\ WKH JRYHUQPHQW $W SUHVHQW WKH FKDLUPDQ
LV D 6XSUHPH $GPLQLVWUDWLYH &RXUW Sw +|JVWD I|UYDOWQLQJVGRPVWROHQ
MXGJH
Deputy chair persons
7KHUHDUHVL[GHSXW\FKDLUSHUVRQV$OOPXVWEHODZ\HUVDQGPXVWQRWEH
HPSOR\HGE\DQLQVXUDQFHFRPSDQ\$WSUHVHQWPRVWRIWKHPDUHMXGJHV
RUIRUPHUMXGJHV
Representatives of insurance companies
7KLUWHHQ PHPEHUV RI WKH FRPPLVVLRQ UHSUHVHQW LQVXUDQFH FRPSDQLHV
7KH\DUHDSSRLQWHGE\WKH6ZHGLVK)LQDQFLDO6XSHUYLVRU\$XWKRULW\Sw
)LQDQVLQVSHNWLRQHQRQWKHUHFRPPHQGDWLRQRIWKH6ZHGLVK0RWRU,QVXUHUV
Sw7UD¿NI|UVlNULQJVI|UHQLQJHQ´7))´
7KHVHPHPEHUVDUHUHTXLUHGWRSRVVHVVH[WHQVLYHDQGLQGHSWKNQRZOHGJH
DQGH[SHULHQFHRIFODLPVKDQGOLQJ
Lay representatives
7KHUH DUH WKLUWHHQ OD\ UHSUHVHQWDWLYHV 7KH\ DUH DSSRLQWHG E\ WKH
6ZHGLVK)LQDQFLDO6XSHUYLVRU\$XWKRULW\Sw)LQDQVLQVSHNWLRQHQRQWKH
UHFRPPHQGDWLRQRIWKHODERXUPDUNHWLQWHUHVWRUJDQLVDWLRQV
When the Commission’s recommendation must be obtained
$V PHQWLRQHG WKH &RPPLVVLRQ¶V DLP LV WR DFKLHYH D XQLIRUP DQG IDLU
VHWWOHPHQWRIFODLPVZLWKLQWKH¿HOGRIWUDI¿FLQVXUDQFH
,QVXUDQFH FRPSDQLHV DUH REOLJDWHG WR REWDLQ WKH &RPPLVVLRQ¶V
UHFRPPHQGDWLRQLQUHVSHFWRI
L ORVVRILQFRPHLIWKHPHGLFDOGLVDELOLW\LVRUPRUHRULIWKHDQQXDO
ORVVRILQFRPHH[FHHGVDFHUWDLQOHYHO
LL SHUVRQDO LQMXU\ SK\VLFDO DQGRU PHQWDO DV ZHOO DV FRVWV DQG ¶RWKHU
LQFRQYHQLHQFHV¶LIWKHPHGLFDOGLVDELOLW\LVRUPRUH
LLLORVVRIVXSSRUWIRUVXUYLYRUVLQFDVHWKHDFFLGHQWUHVXOWVLQGHDWKDQG
LYDUHQZHGDVVHVVPHQWZKHUHWKHUHLVDVXEVWDQWLDOFKDQJHRIWKHFLUFXP
VWDQFHVRQZKLFKWKH&RPPLVVLRQ¶VUHFRPPHQGDWLRQZDVEDVHG
The procedure
7KHLQVXUDQFHFRPSDQ\SUHSDUHVDPHPRUDQGXPSw1lPQGVSURPHPRULD
ZKLFKVHWVRXWDSUHVHQWDWLRQRIWKHPDWWHUDQGDEULHISUHVHQWDWLRQRIDOO
UHOHYDQW IDFWV DQG ¿JXUHV ± LQFOXGLQJ D GHWDLOHG DFFRXQW RI WKH LQMXUHG
SHUVRQ¶VVLWXDWLRQEHIRUHDQGDIWHUWKHDFFLGHQWLQUHVSHFWRILDKLVKHU
ZRUNLQJ DQG OLYLQJ VLWXDWLRQ WKH LQVXUHU¶V YLHZ DQG WKH LQMXUHG SHUVRQV
YLHZ7KHGHJUHHRIPHGLFDOGLVDELOLW\KDVEHHQVHWE\GRFWRUVZLWKVSHFL¿F
NQRZOHGJHRILQVXUDQFHPHGLFLQH,QDGGLWLRQWKHPHPRUDQGXPFRQWDLQV
WKH LQMXUHG SHUVRQ¶V FODLPV ZKHUH VXFK FODLPV DUH VSHFL¿HG DQG WKH
LQVXUDQFHFRPSDQ\¶VFRPSHQVDWLRQRIIHU
7KHPHPRUDQGXPLVVHQWWRWKHLQMXUHGSHUVRQRUKLVKHUUHSUHVHQWDWLYH
DQGKHVKHPD\DGGDGGLWLRQDOGRFXPHQWDWLRQDQGJLYHKLVKHUYLHZ
7KHUHDIWHUWKHPHPRUDQGXPDQGHQFORVXUHVDVZHOODVWKHFRPSOHWHFODLPV
¿OHLVVXEPLWWHGWRWKH&RPPLVVLRQ
7KHPHPEHUVRIWKH&RPPLVVLRQUHFHLYHWKHPHPRUDQGXPZLWKHQFORVXUHV
D FRXSOH RI ZHHNV EHIRUH WKH PHHWLQJ 7KH FDVH LV QRUPDOO\ SUHVHQWHG
E\ D ODZ\HU IURP WKH &RPPLVVLRQ¶V VHFUHWDULDW 6LQFH WKH SDUWLFLSDWLQJ
PHPEHUVRIWKH&RPPLVVLRQKDYHUHDGWKHDFWXDOPHPRUDQGDLQDGYDQFH
WKHSUHVHQWDWLRQLVQRUPDOO\TXLWHEULHIDQGWKHGLVFXVVLRQVWKDWIROORZDUH
IRFXVVHGRQLVVXHVRIFRPSOLFDWHGQDWXUHRURWKHUZLVHRIVSHFL¿FLQWHUHVW
$GLVVHQWLQJRSLQLRQZKLFKLVUHODWLYHO\XQXVXDOPD\EHH[SUHVVHGLQWKH
&RPPLVVLRQ¶VUHFRPPHQGDWLRQ
,WQRUPDOO\WDNHVPRQWKVIURPWKHSRLQWRIWLPHZKHQWKHPDWWHUZDV
VXEPLWWHGXQWLOWKH&RPPLVVLRQ¶VUHFRPPHQGDWLRQLVUHQGHUHG
7KHSURFHHGLQJEHIRUHWKH&RPPLVVLRQLVIUHHRIFKDUJHIRUWKHFODLPDQW
Statistics 2012
PDWWHUVZHUHUHIHUUHGWRWKH&RPPLVVLRQFRQFHUQHGSHUPDQWHQW
GLVDELOLW\EHWZHHQLHQRQPDQGDWRU\PDWWHUV:KLSODVKLQMXULHV
DFFRXQWHGIRU7KHFODLPDQWVZHUHUHSUHVHQWHGE\ODZ\HUVRURWKHU
UHSUHVHQWDWLYHVLQRIWKHVXEPLWWHGPDWWHUV7KH&RPPLVVLRQKHOG
PHHWLQJV
Level of indemnity
7KHOHYHORILQGHPQLW\SURSRVHGE\WKHLQVXUDQFHFRPSDQLHVZDV
LDFFHSWHGLQRIWKHFDVHV
LLUDLVHGLQRIWKHFDVHVDQG
LLLUHGXFHGLQRIWKHFDVHV
3. Insurance Sweden (Sw. Svensk Försäkring)
,QVXUDQFH6ZHGHQSw6YHQVN)|UVlNULQJLVUHVSRQVLEOHIRUDQXPEHURI
LQGXVWU\ZLGHUHYLHZERDUGV7KHUHYLHZERDUGVLVVXHRSLQLRQVRQGLVSXWHV
EHWZHHQ SROLF\KROGHUV DQG LQVXUDQFH FRPSDQLHV 7KH UHYLHZ ERDUGV¶
RSLQLRQV SURYLGH JXLGDQFH IRU H[DPSOH RQ LQWHUSUHWDWLRQ RI LQVXUDQFH
SROLF\FRQGLWLRQVDQGORVVDGMXVWPHQWSUDFWLFHV
5RVH0DULH/XQGVWU|P
3.1 Personförsäkringsnämnden (PFN)
3HUVRQI|UVlNULQJVQlPQGHQ ´3)1´ VROHO\ WULHV GLVSXWHV EHWZHHQ WKH
LQVXUHGDQLQGLYLGXDOFRQVXPHUDQGWKHLQVXUDQFHFRPSDQ\LQPDWWHUV
concerning:
LOLIH
LLVLFNQHVV
LLLDFFLGHQWLQVXUDQFH
ZKHUHPHGLFDODVVHVVPHQWLVUHTXLUHG
PFN’s structure
6L[PHPEHUVSDUWLFLSDWHLQ3)1¶VGHFLVLRQV
7KH3)1LVFRPSRVHGRI
A Chairman or a vice chairman ZKR VKDOO EH lawyers ZLWK VSHFL¿F
TXDOL¿FDWLRQV7KH\PXVWQRWEHHPSOR\HGE\DQLQVXUDQFHFRPSDQ\7KH\
DUHDSSRLQWHGE\,QVXUDQFH6ZHGHQSw6YHQVN)|UVlNULQJ
Two members with extensive claims handling experience 7KH\ DUH
DSSRLQWHGE\,QVXUDQFH6ZHGHQ
Two members representing the consumer 7KH\ DUH DSSRLQWHG E\ WKH
&RQVXPHU$GYLVHUV¶$VVRFLDWLRQSw.RQVXPHQWYlJOHGDUQDVI|UHQLQJ
One advisory doctorH[SHULHQFHGLQLQVXUDQFHPHGLFDOLVVXHV7KHGRFWRU
PXVWQRWEHWLHGWRDQ\LQVXDUDQFHFRPSDQ\
The procedure
$Q DSSOLFDWLRQ UHFHLYHG E\ 3)1 LV IRUZDUGHG WR WKH LQVXUDQFH FRPSDQ\
ZLWKDUHTXHVWIRUFRPPHQWV
2QFHWKHFRPPHQWVDUHUHFHLYHGWKH\DUHVHQWWRWKHLQVXUHGZKRPD\
VXEPLWDGGLWLRQDOFRPPHQWDULHVLQZULWLQJWRWKH3)1
3)1¶V RSLQLRQ LV D QRQELQGLQJ UHFRPPHQGDWLRQ RQO\ $OWKRXJK 3)1¶V
RSLQLRQLVQRWELQGLQJLWLVPRVWO\DFFHSWHGE\WKHLQVXUDQFHFRPSDQ\
1RUPDOO\3)1¶VRSLQLRQLVJLYHQZLWKLQ±PRQWKV
3.2 Ansvarsförsäkringens Personskadenämnd (APN)
$31 WULHV FODLPV KDQGOLQJ LVVXHV FRQFHUQLQJ FRPSHQVDWLRQ IRU SHUVRQDO
LQMXU\ZLWKLQOLDELOLW\LQVXUDQFHDQGRWKHULQVXUDQFHZLWKWKHH[FHSWLRQRI
WUDI¿FLQVXUDQFH
$31¶V RYHUULGLQJ DLP LV WR ZRUN IRU D XQLIRUP DQG IDLU VHWWOHPHQW RI
SHUVRQDO LQMXULHV ZLWKLQ WKH ¿HOG RI OLDELOLW\ LQVXUDQFH RU RWKHU LQVXUDQFH
± ZLWK WKH H[FHSWLRQ RI WUDI¿F LQVXUDQFH ± ZKHUH WKH LQMXUHG SHUVRQ
EDVHGRQWRUWODZLVHQWLWOHGWRFRPSHQVDWLRQ$31GRHVQRWWU\PDWWHUV
IDOOLQJ XQGHU WKH FRPSHWHQFH RI WKH 3KDUPDFHXWLFDO ,QMXULHV %RDUG Sw
/lNHPHGHOVNDGHQlPQGHQ
7KH$31LVFRPSRVHGRI
$&KDLUPDQDQGDYLFHFKDLUPDQERWKDSSRLQWHGE\,QVXUDQFH6ZHGHQ6Z
6YHQVN )|UVlNULQJ 7KH SUHVHQW FKDLUPDQ LV D UHFHQWO\ UHWLUHG 6XSUHPH
&RXUWMXGJH
7ZR PHPEHUV ZLWK H[WHQVLYH DQG LQ GHSWK NQRZOHGJH RI SHUVRQDO LQMXU\
FODLPVKDQGOLQJZLWKLQWKHOLDELOLW\LQVXUDQFH¿HOG%RWKDUHDSSRLQWHGE\
,QVXUDQFH6ZHGHQSwVYHQVN)|UVlNULQJ
7ZR PHPEHUV UHSUHVHQWLQJ FODLPDQWV WKH FRQVXPHU LQWHUHVW %RWK DUH
DSSRLQWHGE\WKH&RQVXPHU$GYLVHUV¶$VVRFLDWLRQSw.RQVXPHQWYlJOHGDUQDV
I|UHQLQJ
7KH FRVWV IRU $31 DUH GLVWULEXWHG EHWZHHQ WKH SDUWLFLSDWLQJ LQVXUDQFH
FRPSDQLHVLQUHODWLRQWRWKHQXPEHURIUHIHUUHGFDVHVIURPWKHUHVSHFWLYH
FRPSDQ\GXULQJWKHFDOHQGDU\HDU
7KHLQVXUDQFHFRPSDQLHVDUHREOLJDWHGWRVHHN$31¶VDGYLFHLQUHVSHFWRI
FRPSHQVDWLRQIRUORVVRILQFRPHFRPSHQVDWLRQIRUGLV¿JXUHPHQWDQG
SHUPDQHQWGLVDELOLW\ZKHUHWKHPHGLFDOGLVDELOLW\LVDWOHDVW
ZKHUH WKH \HDUO\ ORVV RI LQFRPH LV HVWLPDWHG WR DW OHDVW KDOI D EDVH
DPRXQWDWSUHVHQW6(.
LQGHPQLW\IRUORVVRIPDLQWDQHQFHDVDFRQVHTXHQVHRIGHDWK
UHDVVHVVPHQWRIDQQXLW\RUDOXPSVXPLQFHUWDLQFLUFXPVWDQFHV
RWKHULVVXHVLIUHTXHVWHGE\WKHFODLPDQW
:KHUHWKHFODLPDQWLVUHSUHVHQWHGE\D¶VXLWDEOH¶UHSUHVHQWDWLYHDQGWKH
SDUWLHVDUHLQWRWDODJUHHPHQWWKHLQVXUDQFHFRPSDQ\LVQRWREOLJDWHGWR
VXEPLWWKHPDWWHUWR$31
3.3 The Swedish Bar Association Establishes
a Consumer Dispute Board
7KH 6ZHGLVK %DU $VVRFLDWLRQ 6Z$GYRNDWVDPIXQGHW PDNHV SODQV IRU D
&RQVXPHU'LVSXWH%RDUGZLWKWKHWDVNWRWU\FRQVXPHUGLVSXWHVUHODWLQJ
WRODZ\HUV¶DFWLYLWLHV7KLVPHDQVWKHLQWURGXFWLRQRIDQDOWHUQDWLYHGLVSXWH
UHVROXWLRQIDFLOLW\LQDFFRUGDQFHZLWKWKH(&'LUHFWLYHRQ$OWHUQDWLYH'LVSXWH
5HVROXWLRQIRU&RQVXPHUV(&ZKLFKZDVGHFLGHGRQ0DUFK
7KHDLPLVWRJLYHFRQVXPHUVDFFHVVWRDVLPSOHLQH[SHQVLYHDQGH[SHGLWHG
ZD\RIWU\LQJGLVSXWHVZLWKODZ\HUVFRQFHUQLQJHJIHHV,WZLOOEHSRVVLEOH
WR¿OHDQDSSOLFDWLRQYLDWKHZHEVLWH7KHFRVWZLOOEHOLPLWHGWR6(.
5RVH0DULH/XQGVWU|P
7KHWLPHIRUKDQGOLQJPDWWHUVZKLFKZLOOEHLQZULWLQJPXVWQRWH[FHHG
GD\V(DFKSDUW\VKDOOFDUU\LWVRZQFRVWV
0HPEHUVRIWKH6ZHGLVK%DU$VVRFLDWLRQVKDOOEHREOLJDWHGWRSDUWLFLSDWH
LQWKHSURFHGXUHZKLFKPXVWEHLQLWLDWHGZLWKLQRQH\HDUIURPWKHSRLQW
LQWLPHZKHQWKHFRQVXPHU¿OHGDFRPSODLQWZLWKWKHODZ\HU7KHGLVSXWH
PXVWFRQFHUQDQDPRXQWRIDWOHDVW6(.
,WLVSURSRVHGWKDWWKH%RDUGVKDOOFRQVLVWRI¿YHPHPEHUVDµSULYDWHODZ¶
IDPLO\ ODZ FULPLQDO ODZ HWF ODZ\HU D EXVLQHVV ODZ\HU WZR FRQVXPHU
UHSUHVHQWDWLYHVDQGWKH¿IWKPHPEHUVKDOOEHDIRUPHUMXGJHH[SHULHQFHG
LQQRQPDQGDWRU\FLYLOPDWWHUV7KHFKDLUPDQVKDOOEHDODZ\HU
4. The Patient Injury Board
7KH ULJKW WR FRPSHQVDWLRQ IRU LQMXULHV VXVWDLQHG LQ WKH 6ZHGLVK KHDOWK
FDUH V\VWHP LV UHJXODWHG E\ WKH 3DWLHQW ,QMXU\ $FW Sw
3DWLHQWVNDGHODJHQ
$OO 6ZHGLVK FRXQW\ FRXQFLOV DQG UHJLRQV KDYH WDNHQ RXW 3DWLHQW
,QVXUDQFHZLWKWKH3DWLHQW,QVXUDQFH/g)Sw/DQGVWLQJHQVgPVHVLGLJD
)|UVlNULQJVERODJ$SSUR[LPDWHO\LQMXULHVDUHUHSRUWHGHDFK\HDU
$ERXWRIWKHUHSRUWHGLQMXULHVDUHFRPSHQVDWHG
What is covered by the insurance?
L 7KHLQMXU\PXVWKDYHEHHQDYRLGDEOH
LL 7KHLQMXU\PD\EHFRPSHQVDEOHLILWZDVFDXVHGE\GHIHFWLYHPHGLFDO
HTXLSPHQWRUWKHLQFRUUHFWXVHRIVXFKHTXLSPHQW
LLL7KH,QMXU\PD\EHFRPSHQVDEOHLIWKHGLDJQRVLVZDVGHOD\HGDQGWKH
PHGLFDOFRQGLWLRQZRUVHQHGGXHWRWKHGHOD\
LY7KH LQMXU\ PD\ EH FRPSHQVDEOH LI LW ZDV FDXVHG E\ DQ LQIHFWXRV
DJHQW ZKLFK ZDV WUDQVIHUUHG LQ FRQQHFWLRQ ZLWK PHGLFDO FDUH DQG
WUHDWPHQW
Y 7KH LQMXU\ PD\ EH FRPSHQVDEOH LI LW ZDV FDXVHG E\ DQ DFFLGHQW LQ
FRQQHFWLRQZLWKPHGLFDORUGHQWDOFDUHDQG
YL7KHLQMXU\PD\EHFRPSHQVDEOHLILWZDVFDXVHGE\DSKDUPDFHXWLFDO
WKDWZDVLQFRUUHFWO\SUHVFULEHG
5. The Pharmaceutical Injury Board
The Pharmaceutical Insurance (Sw. Läkemedelsförsäkringen)
,Q6ZHGHQWKHUHLVDW\SHRILQVXUDQFHDYDLODEOHIRUWKRVHVXIIHULQJIURP
DGYHUVH HIIHFWV RI SKDUPDFHXWLFDO WUHDWPHQW 7KH LQVXUDQFH SURWHFWV
HYHU\RQHZKRKDVEHHQWUHDWHGZLWKSUHVFULEHGSKDUPDFHXWLFDOSURGXFWV
RUSKDUPDFHXWLFDOVSXUFKDVHGIURPDOHJLWLPDWHVHOOHULQ6ZHGHQ
,QDGGLWLRQWKHLQVXUDQFHFRYHUVSDWLHQWVZKRUHFHLYHGWKHSKDUPDFHXWLFDOV
DWDKRVSLWDORUZKRDUHVXIIHULQJIURPDGYHUVHUHDFWLRQVRUHIIHFWVGXHWR
SDUWLFLSDWLRQLQFOLQLFDOWULDOVFRYHUHGE\WKHLQVXUDQFH
7UDI¿F,QMXULHVDQG:RUN5HODWHG,QMXULHV
7KH7UDI¿F,QVXUDQFHJHQHUDOO\FRYHUVDOVRLQMXULHVFDXVHGGXULQJWUHDWPHQW
RIWUDI¿FLQMXULHV
/LNHZLVH LQMXULHV FDXVHG GXULQJ WUHDWPHQW RI ZRUN UHODWHG LQMXULHV VKDOO
SULPDULO\ EH KDQGOHG E\ $)$ :RUN ,QMXU\ ,QVXUDQFH $)$ LV RZQHG E\
6ZHGHQ¶VODERXUPDUNHWSDUWLHV
The Pharmaceutical Injury Board
7KH 3KDUPDFHXWLFDO ,QMXU\ %RDUG Sw /lNHPHGHOVVNDGHQlPQGHQ LV DQ
LQGHSHQGDQWERG\FRPSRVHGE\PHGLFDOH[SHUWVOD\PHQDQGODZ\HUV
7KH %RDUG FRQVLVWV RI VHYHQ PHPEHUV DQG DV PDQ\ VXEVWLWXWHV 7KH
&KDLUPDQDQGDPDMRULW\RIWKHPHPEHUVDUHDSSRLQWHGE\WKH*RYHUQPHQW
7KH%RDUG¶VUHJXODWLRQVDUHDSSURYHGE\WKH*RYHUQPHQW
7KH%RDUGZKLFKLVLQGHSHQGHQWGHDOVZLWKPDWWHUVRISULQFLSOHLQWHUHVW
DQGGHFLVLRQVIURPWKH3KDUPDFHXWLFDO,QVXUDQFHZKLFKDUHDSSHDOHG%RWK
WKHLQMXUHGSHUVRQDQGWKHLQVXUHUFDQVXEPLWDPDWWHUWRWKH%RDUG
7KH%RDUG¶VGHFLVLRQVDUHDGYLVRU\RQO\LHQRQELQGLQJ
7KH %RDUG¶V GHFLVLRQV ZKLFK DUH GHHPHG RI SULQFLSOH LQWHUHVW DUH
SXEOLVKHG
The Function and Operation
of the Insurance Ombudsman
in Greece through
the Independent Authority
of the Consumer Ombudsman
Dr. Kyriaki Noussia
'U.\ULDNL1RXVVLDLVDQDWWRUQH\DWODZDGPLWWHGWRWKH$WKHQV%DUDVD*UHHN%DUULVWHU
and is licensed to appear before the Supreme Court and the Conseil d’Etat. She specialises
in arbitration and in international commercial law. She has an extensive and wideranging experience inter alia in insurance, reinsurance, marine insurance, arbitration and
PHGLDWLRQEDQNLQJDQGÀQDQFHHQHUJ\RLODQGJDVLQYHVWPHQWDQGHQYLURQPHQWDOODZ
6LQFH VKH KDV VHW XS KHU RZQ OHJDO SUDFWLFH DQG LV DEOH WR JLYH OHJDO DGYLFH RQ
the above areas of law both in a stand-alone and in a transactional context as well as
on the contentious side. Prior to that she has held numerous academic positions abroad,
such as at the University of Hamburg, Faculty of Law and the Max Planck Institute for
Comparative and international Private Law in Hamburg, Germany, where she was an
$OH[DQGHU YRQ +XPEROGW 5HVHDUFK )HOORZ ² 3ULRU WR WKDW VKH KDV EHHQ D
&6(7/HFWXUHULQ&RPPRQ/DZDWWKH8QLYHUVLW\RI%LUPLQJKDP8.%LUPLQJKDP
/DZ6FKRRO,QVKHZDVD)XOEULJKW*UHHFH9LVLWLQJ6FKRODUDW&ROXPELD/DZ
6FKRRO86$6KHLVDOVRDPHPEHURIYDULRXVDVVRFLDWLRQVDQGFRPPLWWHHVLQWKHÀHOGV
of international commercial law, arbitration, international procedural law, insurance and
reinsurance law, transportation law and private international law.
Introduction
,Q *UHHFH WKHUH LV QRW DV RI \HW GLUHFWO\ DQG VHSDUDWHO\ IRUPDWWHG WKH
LQVWLWXWLRQ RI WKH ,QVXUDQFH 2PEXGVPDQ +HQFH WKH UHVSRQVLELOLWLHV
WKDW ZRXOG IDOO XQGHU WKH VFRSH RI RSHUDWLRQ RI WKH LQVWLWXWLRQ RI WKH
,QVXUDQFH2PEXGVPDQDUHFRYHUHGE\DQGIDOOXQGHUWKHUHVSRQVLELOLWLHV
RIWKHLQVWLWXWLRQRIWKH,QGHSHQGHQW$XWKRULW\RIWKH+HOOHQLF&RQVXPHU
2PEXGVPDQDVWKH+HOOHQLF&RQVXPHU2PEXGVPDQFRYHUVSROLF\KROGHUV
LQVRIDUDVFRQVXPHULQVXUDQFHVDUHFRQFHUQHG7KH&RQVXPHU2PEXGVPDQ
RSHUDWHV DV DQ H[WUDMXGLFLDO ERG\ FRQVHQVXDO UHVROXWLRQ RI FRQVXPHU
GLVSXWHVEXWDOVRDVDQDGYLVRU\LQVWLWXWLRQWRWKHVLGHRIWKH6WDWHWRWUHDW
SUREOHPVZLWKLQLWVUHPLW:LWKLQLWVRYHUVLJKWDOVRIDOOWKHORFDO$PLFDEOH
6HWWOHPHQW &RPPLWWHHV ZKLFK DUH ORFDWHG LQ WKH YDULRXV 3UHIHFWXUDO
$XWKRULWLHVRI*UHHFH
7KH)XQFWLRQDQG2SHUDWLRQRIWKH,QVXUDQFH2PEXGVPDQLQ*UHHFH«
7KH &RQVXPHU 2PEXGVPDQ LV D UHODWLYHO\ ,QGHSHQGHQW $XWKRULW\ ZKLFK
ZDVIRUPHGDQGFUHDWHGYLD/DZLQ,WLVEHLQJVXSHUYLVHG
E\WKH*UHHN0LQLVWU\RI'HYHORSPHQW9LDWKHDFWLYDWLRQDQGRSHUDWLRQRI
WKH,QGHSHQGHQW$XWKRULW\RIWKH&RQVXPHU2PEXGVPDQWKH*UHHNSXEOLF
DGPLQLVWUDWLRQLVSODFHGLQOLQHZLWKWKHUHFRPPHQGDWLRQRIWKH(XURSHDQ
8QLRQ LQ DV IDU DV WKH FRQFOXVLRQV RI WKH *UHHQ 3DSHU RQ LPSURYLQJ WKH
IXQFWLRQLQJRIWKH2PEXGVPHQUHVSRQVLEOHIRUKDQGOLQJFRQVXPHUGLVSXWHV
DUHFRQFHUQHGEXWDOVRLQDFFRUGDQFHZLWKDQXPEHURIRWKHUOHJDOWH[WV
DGGUHVVLQJWKHTXHVWLRQRIWKHIRUPDWLRQRIVXFKLQVWLWXWLRQVLQWKH0HPEHU
6WDWHVDQGIXUWKHUPRUHLQDFFRUGDQFHZLWKWKHFUHDWLRQRIDZLGHQHWZRUN
RIQDWLRQDOERGLHVFRXUWVHWWOHPHQWRIFRQVXPHUGLVSXWHV
7KHIRUPDWLRQRIWKH,QGHSHQGHQW$XWKRULW\RIWKH&RQVXPHU2PEXGVPDQ
LVEHLQJVXUURXQGHGDQGKDVEHHQLQVSLUHGE\WKHG\QDPLFVRIDOWHUQDWLYH
H[WUDMXGLFLDO UHVROXWLRQ RI FRQVXPHU GLVSXWHV $OWHUQDWLYH 'LVSXWH
5HVROXWLRQZKLFKKDYHORQJEHHQSURPRWHGE\WKH(XURSHDQ&RPPLVVLRQ
DV D ÀH[LEOH GLUHFW HIIHFWLYH DQG LQH[SHQVLYH ZD\ LI FRPSDUHG WR WKH
WUDGLWLRQDO MXGLFLDO SURFHVV WR VHWWOH GLVSXWHV DULVLQJ RXW RI WUDQVDFWLRQV
EHWZHHQFRQVXPHUVDQGVXSSOLHUV
,Q WKLV FRQWH[W WKH (XURSHDQ &RPPLVVLRQ DGRSWHG 5HFRPPHQGDWLRQ
(&RQWKHSULQFLSOHVDSSOLFDEOHWRWKHERGLHVUHVSRQVLEOHIRURXWRI
FRXUWVHWWOHPHQWRIFRQVXPHUGLVSXWHVDQG5HFRPPHQGDWLRQ
(&FRQFHUQLQJWKHFULWHULDWREHDSSOLHGLQWKHSURFHVVRIFRQFLOLDWLRQVR
WKDWFRQVXPHUVDQGVXSSOLHUVZRXOGUHVWDVVXUHGWKDWWKHLUGLIIHUHQFHVDUH
UHVROYHGZLWKLPSDUWLDOLW\REMHFWLYLW\DQGHIIHFWLYHQHVV
2WKHUUHOHYDQWLQVWUXPHQWVDW(XURSHDQOHYHOLQUHODWLRQWRWKHKLVWRU\RI
FRXUWVHWWOHPHQWRIFRQVXPHUGLVSXWHVDUH
D WKH SURSRVDO IRU D 'LUHFWLYH RI WKH (XURSHDQ 3DUOLDPHQW DQG RI WKH
&RXQFLO RQ FHUWDLQ DVSHFWV RI PHGLDWLRQ LQ FLYLO DQG FRPPHUFLDO PDWWHUV
>&20 ¿QDO@ 7KLV SURSRVDO LV LQWHQGHG ¿UVW WR HVWDEOLVK D
PLQLPXP KDUPRQL]DWLRQ DW (XURSHDQ OHYHO DV WR FLYLO SURFHHGLQJV DQG
VHFRQGO\WRSURPRWHWKHXVHRIPHGLDWLRQLQWKH(XURSHDQ&RXUWVFUHDWLQJ
VRPHQHFHVVDU\WRROVDQG
E 7KH &RPPLVVLRQ &RPPXQLFDWLRQ RI $SULO RQ EURDGHQLQJ
FRQVXPHU DFFHVV WR RWKHU GLVSXWH UHVROXWLRQ V\VWHPV >&20 ¿QDO@
7KH &RQVXPHU 2PEXGVPDQ DOEHLW RQH RI WKH LQGHSHQGHQW DXWKRULWLHV RI
WKH*UHHN6WDWHQHYHUWKHOHVVLWGRHVQRWDGKHUHWRWKHFOHULFDOKLHUDUFK\
RIDQ\0LQLVWU\RIWKH6WDWH7KLVGLIIHUHQWLDWHVWKH&RQVXPHU2PEXGVPDQ
IURP WKH +HOOHQLF 2PEXGVPDQ ZKLFK LV D FRQVWLWXWLRQDOO\ VDQFWLRQHG
,QGHSHQGHQW$XWKRULW\IRXQGHGLQ2FWREHUDQGRSHUDWLQJXQGHUWKH
'U.\ULDNL1RXVVLD
SURYLVLRQV RI /DZ 7KH +HOOHQLF 2PEXGVPDQ DV VXFK KDV D
ZLGHUVFRSHRIDFWLYLW\LIFRQWUDVWHGWRWKH&RQVXPHU2PEXGVPDQ
The Function of the Independent Authority of the Consumer
Ombudsman as far as Consumer Insurances are concerned.
7KH&RQVXPHU2PEXGVPDQGHDOVRQDUHJXODUEDVLVZLWKDODUJHDPRXQW
RI FRQVXPHU LQVXUDQFH FDVHV 7KH SURFHGXUH RI D SHWLWLRQ RU PRWLRQ LQ
IURQW RI WKH &RQVXPHU 2PEXGVPDQ LQYROYHV D KHDULQJ ZLWK RU ZLWKRXW
WKH UHSUHVHQWDWLRQ E\ D ODZ\HU 7KH &RQVXPHU 2PEXGVPDQ DGGUHVVHV
WKHFDVHVRILWVFRPSHWHQFHHLWKHUE\UDLVLQJLWVRZQPRWLRQH[RI¿FLR
RU IROORZLQJ D VLJQHG SHWLWLRQ RI DW OHDVW RQH VWDNHKROGHU ZLWKLQ WKUHH
PRQWKVDIWHUWKHSDUW\FRQFHUQHGEHFDPHIXOO\DZDUHRIDQDFWRURPLVVLRQ
DGYHUVHO\ DIIHFWLQJ KLP DQG FRQVWLWXWLQJ D FRQVXPHU GLVSXWH ,Q WKH
VDPHZD\WKH&RQVXPHU2PEXGVPDQDGGUHVVHVDOVRFDVHVGHDOLQJZLWK
UHTXHVWV IURP FRQVXPHUV RU FRQVXPHU DVVRFLDWLRQV DQG VXSSOLHUV ZKLFK
KDYHEHHQUHIXVHGWREHSUHVHQWHGDQGEHGHDOWZLWKE\RWKHUHVWDEOLVKHG
ERGLHV UHVSRQVLEOH IRU WKH H[WUDMXGLFLDO VHWWOLQJ RI LQGLYLGXDO FRQVXPHU
GLVSXWHV 7KH &RQVXPHU 2PEXGVPDQ GRHV QRW GHDO ZLWK FDVHV SHQGLQJ
EHIRUHWKHMXGLFLDODXWKRULWLHVRUZLWKUHIHUHQFHVGHHPHGPDQLIHVWO\YDJXH
XQIRXQGHGWULYLDORUZKLFKDUHEHLQJH[HUFLVHGLPSURSHUO\RULQEUHDFKRI
WKHSULQFLSOHRIJRRGIDLWK
7KHGHFLVLRQVRIWKH&RQVXPHU2PEXGVPDQEHDUKHDY\OHJDODXWKRULW\DQG
DUHEHLQJSXEOLVKHGLQOHDGLQJODZMRXUQDOV$OVRWKHGHFLVLRQVRI&RQVXPHU
2PEXGVPDQDUHRIWHQEHLQJUHIHUUHGWRLQWKHWH[WRIMXGLFLDOGHFLVLRQVRI
RUGLQDU\VWDWHFRXUWVDQGLQWKDWVHQVHKHOSWKHSURFHVVRIWKHFUHDWLRQRI
OHJDOSUHFHGHQW
7KH&RQVXPHU2PEXGVPDQGRHVQRW¿QDOO\UHVROYHWKHGLVSXWHVVXEPLWWHG
XQGHU LW EXW RQO\ PDNHV UHFRPPHQGDWLRQV 'XH WR WKH IDFW WKDW WKH
RSHUDWLRQRIWKH&RQVXPHU2PEXGVPDQLVEDVHGRQ(8ODZDQGLQFHQWLYHV
GHVLJQDWHGIRUWKHSURPRWLRQRI$'5DQGLVDUHVXOWRIWKHQHHGIRU$'5
KHQFHLWVGHFLVLRQVDUHFDWHJRUL]HGDVUHFRPPHQGDWLRQV1RWZLWKVWDQGLQJ
WKH DERYH FDWHJRUL]DWLRQ DV QRQELQGLQJ UHFRPPHQGDWLRQV VWLOO WKH
GHFLVLRQV RI WKH &RQVXPHU 2PEXGVPDQ DUH FDSDEOH RI KROGLQJ VRPH
LQÀXHQFH7KH&RQVXPHU2PEXGVPDQKDVYDULRXVFRQFLOLDWLRQFRPPLWWHHV
DQGSURYLGHVLWVVHUYLFHVWRWKHFRQVXPHUVIRUIUHH6WDWLVWLFVKDYHVKRZQ
WKDWLQ*UHHFHDVIDUDVFRQVXPHULQVXUDQFHGLVSXWHVDUHFRQFHUQHGRQO\
SROLF\KROGHUVZKRDUHFRQVXPHUVKDYHVRXJKWUHFRXUVHWRWKH&RQVXPHU
2PEXGVPDQDQGQRWLQVXUDQFHFRPSDQLHV
1RWZLWKVWDQGLQJWKH,QGHSHQGHQW$XWKRULW\RIWKH&RQVXPHU2PEXGVPDQ
ZKLFKinter aliaGHDOVZLWKFDVHVRIFRQVXPHULQVXUDQFHGLVSXWHVDQRWKHU
UHVSRQVLEOHDXWKRULW\IRUVXFKFDVHVLVWKDWRIWKH*HQHUDO6HFUHWDULDWIRU
7KH)XQFWLRQDQG2SHUDWLRQRIWKH,QVXUDQFH2PEXGVPDQLQ*UHHFH«
&RQVXPHU $IIDLUV 7KH *HQHUDO 6HFUHWDULDW IRU &RQVXPHU $IIDLUV IRUPV
SDUW RI WKH *UHHN *RYHUQPHQW DV LW EHORQJV WR DQG LV SDUW RI WKH *UHHN
0LQLVWU\RI'HYHORSPHQW7KH*HQHUDO6HFUHWDULDWIRU&RQVXPHU$IIDLUVKDV
WKHDELOLW\WRLPSRVH¿QHVRQSURYLGHUVDQGKHQFHLQWHUPVRILQVXUDQFH
LW FDQ DOVR LPSRVH ¿QHV WR LQVXUDQFH XQGHUWDNLQJV ZKR DFW DJDLQVW WKH
UHDVRQDEOHLQWHUHVWRIFRQVXPHUSROLF\KROGHUV,IIRUH[DPSOHWKHUHLVDQ
DEXVLYHRUDQRQWUDQVSDUHQWFODXVHLQDQLQVXUDQFHFRQWUDFWWKH*HQHUDO
6HFUHWDULDWIRU&RQVXPHU$IIDLUVPD\LPSRVHD¿QH,WQHHGEHVWDWHGDW
WKLVSRLQWWKDWVXFKDFRQWUROLHIRUH[DPSOHDFRQWUROIRUWKHH[LVWHQFH
RIDQ\DEXVLYHRUQRQWUDQVSDUHQWFODXVHVLQLQVXUDQFHFRQWUDFWVLVDOVR
EHLQJH[HUFLVHGE\WKHLQVXUDQFHFRPSDQLHV+RZHYHULQWKLVVHQVHWKH
*HQHUDO6HFUHWDULDWIRU&RQVXPHU$IIDLUVLVSODFHGDERYHWKHSULYDWHVHOI
FRQWURORILQVXUDQFHFRPSDQLHV
Mediation, Conciliation and Arbitration as Opposed to the recourse
to the Consumer Ombudsman
7KH UHFRXUVH WR WKH &RQVXPHU 2PEXGVPDQ LV EHLQJ GLVWLQJXLVKHG IURP
WKH UHFRXUVH WR RWKHU $'5 IRUPV VXFK DV PHGLDWLRQ FRQFLOLDWLRQ DQG
DUELWUDWLRQ$OOWKUHHPHGLDWLRQFRQFLOLDWLRQDQGDUELWUDWLRQH[LVWLQ*UHHFH
DQGLQWKH*UHHNOHJDOV\VWHPKRZHYHUPHGLDWLRQDQGFRQFLOLDWLRQDUHQRW
HVWDEOLVKHG E\ ODZ DQG DUH EHLQJ XVHG IRU WKH UHVROXWLRQ RI FRPPHUFLDO
QRQFRQVXPHUGLVSXWHV5HFHQWO\KRZHYHUWKHFHUWL¿FDWLRQRIPHGLDWRUV
LQ*UHHFHDOVRIRUFRQVXPHUGLVSXWHVKDVEHHQHVWDEOLVKHGVRDVWRKDYH
GLVSXWHVUHVROYHGXQGHUPHGLDWLRQDQGVRDVQRWWRKDYHWKHQHHGWRUHVRUW
WRRUGLQDU\VWDWHFRXUWVDOOWKHWLPH
,I D FRPSDULVRQ LV PDGH RQH FRXOG VD\ WKDW PHGLDWLRQ LV FRQVLGHUHG DV
D PRUH QHXWUDO SURFHVV WR ZKLFK ERWK SDUWLHV UHVRUW WR ,Q WKH HYHQW RI
UHFRXUVHWRWKH&RQVXPHU2PEXGVPDQZHKDYHRQO\RQHSDUW\UHVRUWLQJ
WRLWLHWKHFRQVXPHUDQGPRUHRYHUWKLVLVDQ$'5PHWKRGRIGLVSXWH
UHVROXWLRQZKLFKLVQRQFRPPLWWDO+HQFHLWFRXOGEHVDLGWKDWWKHUROHRIWKH
&RQVXPHUKDVDPRUDOFKDUDFWHULQIDYRURIWKHFRQVXPHULHE\GH¿QLWLRQ
LW SURWHFWV WKH FRQVXPHU :LWKLQ WKH LQVWLWXWLRQDO UROH RI WKH &RQVXPHU
2PEXGVPDQFRPHVQRWRQO\WKHQHHGDQGREOLJDWLRQWRSURWHFWFRQVXPHUV
EXWDOVRWKHQHHGDQGREOLJDWLRQWRXSGDWHFRQVXPHUVJHQHUDOO\GHIHQG
WKHLULQWHUHVWVDQGLQWKDWVHQVHDOVRDFWLQDZD\DVDpro bonoODZ\HURI
WKHFRQVXPHU
,I ZH ZHUH WR SULRULWL]H WKH YDULRXV DXWKRULWLHV DQG OHYHOV RI FRQVXPHU
SURWHFWLRQ RIIHUHG ZLWK UHJDUG WR GLIIHUHQFHV DULVLQJ RXW RI FRQVXPHUV
LQVXUDQFHV ¿UVW FRPHV WKH DOUHDG\ LPSRVHG E\ (8 ODZ REOLJDWLRQ RI WKH
LQVXUDQFH FRPSDQLHV WR KDYH LQ RSHUDWLRQ D PHFKDQLVP IRU KDQGOLQJ
FRPSODLQWVVHFRQGO\FRPHVWKHDYDLODELOLW\RIUHFRXUVHWRWKH&RQVXPHU
2PEXGVPDQ IRU DQ DPLFDEOH $'5 WKLUGO\ FRPHV WKH PHFKDQLVP RI WKH
'U.\ULDNL1RXVVLD
*HQHUDO 6HFUHWDULDW IRU &RQVXPHU $IIDLUV ZKLFK LPSRVHV ¿QHV IRXUWKO\
FRPHVWKHDYDLODELOLW\RIPHGLDWLRQSURFHVVWKHQFRPHVWKHDYDLODELOLW\RI
DUELWUDWLRQIRUWKHUHVROXWLRQRIQRQFRQVXPHULQVXUDQFHFDVHVDQGODVWO\
FRPHVWKHDYDLODELOLW\RIWKHRSWLRQWRUHVRUWWR6WDWHFRXUWV
The Way Forward
7KHUH KDYH EHHQ PDQ\ WDONV DQG SUHVVXUHV IRU WKH FUHDWLRQ RI D VSHFLDO
$XWKRULW\RIWKH,QVXUDQFH2PEXGVPDQLQ*UHHFHDVZHOOLQOLQHZLWKWKH
H[LVWHQFHRIWKHVDLGDXWKRULW\LQVRPHRWKHUFRXQWULHV+HQFHDGUDIWODZ
KDVEHHQFUHDWHGZKLFKHQWDLOVDQGHQYLVDJHVWKHFUHDWLRQRIWKHVHSDUDWH
$XWKRULW\H[FOXVLYHO\IRUWKH,QVXUDQFH2PEXGVPDQLQ*UHHFHKRSHIXOO\
E\WKHHQGRIWKHFDOHQGDU\HDU
The Finnish System
for Dispute Resolutions
Taisto Hujala, Legal Counsel
If P&C Insrurance Company Ltd, Finland
Member of the AIDA Presidential Council
and the Executive Committee
7DLVWR+XMDODKDVEHHQZRUNLQJDVOHJDOFRXQVHODQGGHSDUWPHQWPDQDJHULQDYHU\ODUJH
number of areas involving insurance. He has been a member of several claims boards
037/ZRUNHU·VFRPSHQVDWLRQDQGDFFRPSOLVKHVYDULRXVWDVNV9LFH3UHVLGHQWRIWKH
)LQQLVK3DWLHQW&ODLPV%RDUG3UHVLGHQWRI7KH)LQQLVK,QVXUDQFH/DZ\HUV·$VVRFLDWLRQ
$,'$6HFWLRQ0HPEHURIWKH3UHVLGHQWLDO&RXQFLORI$,'$3UHVLGHQWRI7KH([SHUW
)RUXPLQ7KH)LQDQFLDODQG,QVXUDQFH,QVWLWXWH0HPEHURIWKHSROLWLFROHJDOFRPPLWWHH
LQWKH)LQQLVK/DZ\HUV·$VVRFLDWLRQDQG0HPEHURIWKH%RDUGRI$OXPQL$VVRFLDWLRQLQ
Helsinki University.
7KLV SUHVHQWDWLRQ LV D VKRUW VXPPDU\ RI WKH )LQQLVK V\VWHP IRU GLVSXWH
UHVROXWLRQVLQLQVXUDQFHLQGXVWU\
,Q )LQODQG LW KDV DOZD\V EHHQ YHU\ QDWXUDO WR KDYH FHUWDLQ DQG VRPH
\HDUV DJR VHYHUDO FODLPV ERDUGV IRU VROYLQJ LQVXUDQFH FODLP FDVHV 7KH
SXUSRVH KDV EHHQ WR FUHDWH YHU\ HDV\ IDVW DQG HFRQRPLFDOO\ QRW FRVWO\
ZD\VIRULQVXUDQFHFOLHQWVWRKDYHWKHLUSUREOHPVVROYHG(VSHFLDOO\ZKHQ
WKHLQWHUHVWRIDFODLPLVQRWKLJKGLVSXWHVVKRXOGEHVROYHGLQDQHDVLHVW
SRVVLEOHZD\
7KHFODLPVERDUGVLQ)LQODQGFDQEHGLYLGHGDWOHDVWWRWKHQH[WGLIIHUHQW
categories:
7KH &ODLPV ERDUG ZKLFK KDQGOHV FODLPV FRQFHUQLQJ all consumer
issuesLQFOLQVXUDQFH
7KH&ODLPVERDUGVZKLFKKDQGOHFODLPVDQGJLYHUHFRPPHQGDWLRQV
concerning PDQGDWRU\LQVXUDQFH
7KH &ODLPV ERDUG ZKLFK KDQGOH FODLPV FRQFHUQLQJ RQO\ YROXQWDU\
insurance
$SSHDORUJDQVLQinsurance companies
2UJDQVIRU6RFLDO,QVXUDQFHPDWWHUV
'LVWULFW&RXUW±$SSHDO&RXUW±6XSUHPH&RXUWWKHJHQHUDO&RXUWV
7DLVWR+XMDOD
1 The Claims board for all consumer issues
7KH&RQVXPHU&RPSODLQW%RDUG
7KH %RDUG FDQ JLYH UHFRPPHQGDWLRQV ZLGHO\ LQ GLVSXWHV ZKLFK UHODWH
WRLVVXHVVXFKDVVDOHRIUHDOHVWDWHRUQRQUHDOHVWDWHSURSHUW\VDOHRI
VHUYLFHHWF7KHVHUYLFHFDQDOVRFRQFHUQYROXQWDU\LQVXUDQFHFODLPV7KH
FODLPDQWKDVWREHFRQVLGHUHGDVDFRQVXPHUDQGWKHFRXQWHUSDUWKDV
WREHDFRPSDQ\RUDQHQWUHSUHQHXU$GLVSXWHEHWZHHQWZRFRPSDQLHV
RUEHWZHHQWRFRQVXPHUVFDQQRWEHVROYHGWKHUH
7KH%RDUGFDQRQO\JLYHUHFRPPHQGDWLRQVZKLFKFDQQRWEHHQIRUFHGE\
FRHUFLYHPHDVXUHV7KH&RQVXPHUFDQQRWDSSHDOWKHUHFRPPHQGDWLRQ
7KHPHPEHUVRIWKH%RDUGUHSUHVHQW&RQVXPHUDXWKRULWLHVDQGGLIIHUHQW
EXVLQHVVVHFWRUV
2 The Claims board which handle claims and give
recommendations concerning mandatory insurance
7UDI¿F$FFLGHQW%RDUG
7KH7UDI¿F$FFLGHQW%RDUGFDQJLYHUHFRPPHQGDWLRQVERWKWRWKHLQVXUHG
SDUWV DQG WR WKH ,QVXUDQFH FRPSDQLHV ZKHQ WKH 7UDI¿F $FFLGHQW $FW
LVFRQFHUQHG7KHUHFRPPHQGDWLRQVFDQFRQFHUQLQGLYLGXDOTXHVWLRQV
VXFKDVFDXVDWLRQWKHDPRXQWRIGLIIHUHQWGDPDJHVHWF
7KH7UDI¿F$FFLGHQW%RDUGDOVRJLYHV\HDUO\FHUWDLQJHQHUDOJXLGHOLQHV
DQGUXOHVWRLQVXUDQFHFRPSDQLHVIRUWKHLUFODLPVKDQGOLQJ(VSHFLDOO\
WKHJXLGHOLQHVFRQFHUQLQJSHUVRQDOLQMXULHVVXFKDVFRPSHQVDWLRQOHYHO
IRUSDLQDQGVXIIHULQJHWFFDQEHLQWHUSUHWHGLQRWKHULQVXUDQFHVHFWRUV
OLNHSDWLHQWLQVXUDQFHOLDELOLW\LQVXUDQFHDQGFULPLQDOFDVHVLQ'LVWULFW
&RXUWVHWF
7KH PHPEHUV UHSUHVHQW GLIIHUHQW DXWKRULWLHV PLQLVWU\ WUDI¿F
DVVRFLDWLRQVDQGFRQVXPHUV%HFDXVHRIWKHVHYHUDOFDVHVFRQFHUQLQJ
SHUVRQDO LQMXULHV WKHUH DUH PHPEHUV ZLWK PHGLFDO H[SHUWLVH VXFK DV
RUWKRSHGLVWVWUDXPDWRORJLVWVQHXURORJLVWVHWF
7KH3DWLHQW,QMXULHV%RDUG
7KH3DWLHQW,QMXULHV%RDUGLVD&ODLPV%RDUGZKLFKKDQGOHVRQO\FDVHV
ZKLFKUHODWHWR3DWLHQW,QMXULHV$FW7KH%RDUGFDQJLYHVWDWHPHQWVDQG
UHFRPPHQGDWLRQV ZKLFK FDQQRW EH HQIRUFHG E\ FRHUFLYH PHDVXUHV
7KHERDUGJLYHVVWDWHPHQWVDOVRWR'LVWULFW&RXUWVZKHQWKH\GHDOZLWK
D 3DWLHQW LQMXU\ FDVH 7KH %RDUG FDQ DOVR JLYH JHQHUDO JXLGHOLQHV IRU
FODLPVKDQGOLQJ
7KHPHPEHUVRIWKHERDUGUHSUHVHQWWKH0LQLVWU\RI6RFLDO$IIDLUVDQG
+HDOWK LQVXUDQFH EUDQFK WRUW ODZ DQG YHU\ ZLGHO\ GLIIHUHQW PHGLFDO
VHFWRUVDQGXQLWV
7KH)LQQLVK6\VWHPIRU'LVSXWH5HVROXWLRQV
3 The Claims boards which handle claims concerning only
voluntary insurance
,Q)LQODQGZHKDYHDORQJKLVWRU\RIKDYLQJYROXQWDU\RUJDQVIRUGLVSXWH
UHVROXWLRQV 7KH\ KDYH EHHQ HVWDEOLVKHG E\ FRQWUDFWV EHWZHHQ WKH
,QVXUDQFHVHFWRUDQGWKH&RQVXPHU$JHQF\
7KH )LQQLVK )LQDQFLDO 2PEXGVPDQ %XUHDX IRUPHUO\ 7KH )LQQLVK
,QVXUDQFH 2PEXGVPDQ %XUHDX ZDV HVWDEOLVKHG LQ ,W LV D
YROXQWDU\ RUJDQ ZKLFK JLYHV DGYLFH DQG DVVLVWDQFH WR LQVXUDQFH DQG
EDQNFRQVXPHUV
5HODWHGWRWKH%XUHDXWKHUHDUHVSHFLDO&RPSODLQWV%RDUGVIRULQVXUDQFH
EDQNLQJ DQG VHFXULWLHV 7KH ,QVXUDQFH &RPSODLQWV %RDUG JLYHV \HDUO\
UHFRPPHQGDWLRQV LQ DERXW FODLP LVVXHV %HFDXVH RI LWV OHJDO
XQRI¿FLDOVWDWXVWKH%RDUGFDQRQO\JLYHUHFRPPHQGDWLRQVEXWWKH\DUH
DOPRVWSHUFHQWIROORZHGE\LQVXUDQFHDQGEDQNFRPSDQLHV
4 The Appeal organs in Insurance companies
6RPH )LQQLVK ,QVXUDQFH FRPSDQLHV KDYH RUJDQL]HG WKHLU RZQ DSSHDO
RUJDQV LQVLGH WKH FRPSDQLHV 7KRVH RUJDQV FDQ EH EXLOW E\ WKH
FRPSDQ\¶V RZQ SHUVRQQHO RU WKHUH FDQ EH FXVWRPHUV LQYROYHG ,W LV
FOHDU WKDW LI WKH DSSHDO RUJDQ RI DQ LQVXUDQFH FRPSDQ\ KDV RQO\ LWV
RZQSHUVRQQHOLWFDQQRWORRNVRREMHFWLYHWKDQLQWKHFDVHZKHUHWKH
RUJDQKDVPHPEHUVIURPRXWVLGHWKHFRPSDQ\%XWDOVRZKHQWKHUH
DUHFRPSDQ\¶VRZQSHRSOHLQWKHDSSHDORUJDQLWFDQJLYHXVHIXOKHOS
DQG LQIRUPDWLRQ EHWZHHQ WKH FXVWRPHU DQG WKH FRPSDQ\ ,W FDQ DOVR
JLYH H[WUD LQIRUPDWLRQ WR ERWK WKH FXVWRPHUV DQG DOVR WR KHOS WKH
FRPSDQ\RUJDQL]DWLRQWRLPSURYHLWVSURGXFWVDQGWRZULWHWKHWHUPV
DQGFRQGLWLRQVLQDPRUHXQGHUVWDQGDEOHZD\
,Q )LQODQG DW OHDVW RQH ,QVXUDQFH &RPSDQ\ KDV D FHUWDLQ &XVWRPHU
Panel IRU FODLPV LVVXHV ZKHUH WKH PHPEHUV RI WKH SDQHO DUH FKRVHQ
DPRQJWKHFRPSDQ\¶VRZQFXVWRPHUV7KHFXVWRPHUPHPEHUVRIWKH
SDQHODUHFKRVHQHYHU\WZR\HDUVDQGWKHUHLVRQHPHPEHUIURPWKH
FRPSDQ\DQGDQRXWVLGHODZ\HUDVDFKDLUSHUVRQ
5 Organs for Social Insurance matters
7KH$FFLGHQW$SSHDO%RDUG
7KH %RDUG LV DQ LPSRUWDQW SDUW RI WKH DSSHDO V\VWHP LQ WKH VRFLDO
LQVXUDQFH VFKHPH ,W LV WKH ¿UVW LQVWDQFH GHDOLQJ ZLWK PDWWHUV IDOOLQJ
XQGHUWKHVFRSHRIVWDWXWRU\DFFLGHQWLQVXUDQFH
7KH DSSHDOV FDQ UHODWH WR GHFLVLRQV PDGH P\ LQVXUDQFH FRPSDQLHV
FRQFHUQLQJ DFFLGHQWV DW ZRUN RFFXSDWLRQDO GLVHDVHV DFFLGHQWV WR
7DLVWR+XMDOD
DJULFXOWXUDO HQWUHSUHQHXUV DQG DFFLGHQWV DQG GLVHDVHV VXIIHUHG E\
VROGLHUVGXULQJQDWLRQDOVHUYLFH7KHGHFLVLRQVFDQEHHQIRUFHGLQWKH
VDPHZD\DVOHJDOO\YDOLGOLWLJDWLRQMXGJHPHQWV
7KH%RDUGKDVODZ\HUPHPEHUVSK\VLFLDQPHPEHUVDQGDOVRPHPEHUV
ZKRDUHIDPLOLDUZLWKWKHZRUNLQJOLIHFRQGLWLRQVDQGWKHODERXUPDUNHW
DQGWKHPHPEHUVDUHDSSRLQWHGE\WKHSURSRVDOVE\WKHHPSOR\HHDQG
HPSOR\HUDVVRFLDWLRQV
7KH(PSOR\PHQW3HQVLRQV$SSHDO%RDUG
7KH%RDUGKDVPDQ\VLPLODUIHDWXUHVFRPSDUHGWRWKH$FFLGHQW$SSHDO
%RDUG ,W KDQGOHV DOO SHQVLRQ DSSHDO PDWWHUV ZKHWKHU WKH\ FRQFHUQ
SULYDWH RU SXEOLF VHFWRU ,W LV LQGHSHQGHQW IURP SHQVLRQ LQVXUDQFH
FRPSDQLHV
,W KDV PHPEHUV ZKR UHSUHVHQW HPSOR\HH DQG HPSOR\HU DVVRFLDWLRQV
ERWKSULYDWHVHFWRUDQGSXEOLFVHFWRULQFOXGLQJWKHPXQLFLSDOLWLHVDQG
WKHVWDWHDQGRIFRXUVHODZ\HUDQGSK\VLFLDQPHPEHUV
7KHGHFLVLRQVFDQDOVREHHQIRUFHGWKHVDPHZD\DVWKHOHJDOO\YDOLG
OLWLJDWLRQMXGJHPHQWV
7KH,QVXUDQFH&RXUW
7KLVVSHFLDOFRXUWLVDVSHFLDODSSHDOFRXUWIRUDSSHDOV
7KH'LVWULFW&RXUW±7KH$SSHDO&RXUW±7KH6XSUHPH&RXUWWKH
general Courts
,Q)LQODQGWKHUHDUH'LVWULFW&RXUWV$SSHDO&RXUWVDQGWKH6XSUHPH
&RXUW7KHVHFRXUWVVHUYHDVJHQHUDOFRXUWVLQDOOOHJDOPDWWHUZKLFKDUH
QRWKDQGOHGE\WKHVSHFLDOERDUGVRUWKH,QVXUDQFH&RXUWRUE\VSHFLDO
$GPLQLVWUDWLYH&RXUWV
,QVXUDQFHOLWLJDWLRQVZKLFKFRQFHUQPRWRUWKLUGSDUW\OLDELOLW\RUSDWLHQFH
LQVXUDQFH RU DQ\ YROXQWDU\ LQVXUDQFH FDQ JR EHIRUH WKHVH JHQHUDO
FRXUWV7KHGHFLVLRQVFDQQDWXUDOO\EHHQIRUFHG
100
Dispute Resolution in Insurance:
The South African Ombud
1
Prof. Birgit Kuschke
University of Pretoria
3URI%LUJLW.XVFKNHLVDQ$VVRFLDWH3URIHVVRULQWKH'HSDUWPHQWRI3ULYDWH/DZDWWKH
8QLYHUVLW\RI3UHWRULD3UHWRULD6RXWK$IULFD6KHKROGVWKHGHJUHHV%/&FXPODXGH
//%FXPODXGHDQG//'6KHWHDFKHVFRQWUDFWODZLQVXUDQFHODZFRQVWUXFWLRQDQG
HQJLQHHULQJ ODZ DQG GUDIWLQJ RI FRQWUDFWV %LUJLW LV DQ DGPLWWHG$WWRUQH\ 1RWDU\ DQG
&RQYH\DQFHURIWKH+LJK&RXUWRI6RXWK$IULFD6KHKDVDOVREHHQDPHPEHURI$,'$
VLQFH DQG D PHPEHU RI WKH 3UHVLGHQWLDO &RXQFLO VLQFH 6KH LV FXUUHQWO\ D
PHPEHURIWKH&RQVXPHU3URWHFWLRQDQG'LVSXWH5HVROXWLRQZRUNLQJ3DUW\RI$,'$
1. Overview of South African Insurance legislation
1.1 General
7KHIROORZLQJVWDWXWHVDSSO\WRWKHLQVXUDQFHLQGXVWU\DQGHDFKFRQWDLQV
SURYLVLRQV UHODWLQJ WR GLVSXWH UHVROXWLRQ ZLWKLQ WKDW VSHFL¿F VHFWRU RI
insurance business:
/RQJWHUP,QVXUDQFH$FW26KRUWWHUP,QVXUDQFH$FW)LQDQFLDO$GYLVRU\
DQG,QWHUPHGLDU\6HUYLFHV$FW4DQG3ROLF\KROGHU3URWHFWLRQ5XOHVLVVXHGLQ
WHUPVRIWKH/RQJWHUP,QVXUDQFH$FWDQG6KRUWWHUP,QVXUDQFH$FWV
7KHLQGXVWU\LVUHJXODWHGE\WKH)LQDQFLDO6HUYLFHV%RDUGRUµ)6%¶
)RUJHQHUDORULHQWDWLRQWKHVFRSHDQGDSSOLFDWLRQVRIWKHGLIIHUHQWDFWVDUH
VHWRXWEULHÀ\EHORZIROORZHGE\DGLVFXVVLRQRQWKHUROHRIWKH2PEXGLQ
HDFKRIWKHVHFWRUV
1.2 The Long-term Insurance Act
,QDFFRUGDQFHZLWKWKLV$FWKHUHLQDIWHUµ/7,$¶DORQJWHUPSROLF\´PHDQV
DQ DVVLVWDQFH SROLF\ D GLVDELOLW\ SROLF\ IXQG SROLF\ KHDOWK SROLF\ OLIH
1
7KHQHXWUDOJHQHULFWHUP2PEXGLVPRUHRIWHQXVHGDQGQRWWKHWHUP2PEXGVPDQDV
XVHGLQRWKHUFRXQWULHVVHHWKHJHQHUDOZHEVLWHZZZRPEXGFR]D
2
$FWRI
$FWRI
4
$FWRI
)LQDQFLDO6HUYLFHV%RDUG$FWRI
3URI%LUJLW.XVFKNH
101
SROLF\ RU VLQNLQJ IXQG SROLF\ RU D FRQWUDFW FRPSULVLQJ D FRPELQDWLRQ RI
DQ\RIWKRVHSROLFLHVDQGLQFOXGHVDFRQWUDFWZKHUHE\DQ\VXFKFRQWUDFW
LVYDULHG6
7KH$FWSURYLGHVIRUWKHUHJLVWUDWLRQRIORQJWHUPLQVXUHUVIRUWKHFRQWURORI
FHUWDLQDFWLYLWLHVRIORQJWHUPLQVXUHUVDQGLQWHUPHGLDULHVDQGIRUPDWWHUV
FRQQHFWHG WKHUHZLWK $V WKH $FW LV RI D UHJXODWRU\ QDWXUH LW SUHVFULEHV
UXOHVIRUWKHUHJLVWUDWLRQRILQVXUHUVEXVLQHVVDQGDGPLQLVWUDWLYHSUDFWLFHV
DQGSROLFLHVRILQVXUHUVDQGLQWHUPHGLDULHV¿QDQFLDODUUDQJHPHQWVMXGLFLDO
PDQDJHPHQW DQG WKH ¿QDO ZLQGLQJXS RI LQVXUHUV 7KH $FW DOVR FUHDWHV
SXQLVKDEOHRIIHQFHVDQGSUHVFULEHVSHQDOWLHVIRUQRQFRPSOLDQFH'LVSXWHV
DUH UHIHUUHG WR WKH /RQJWHUP 2PEXG RU LQ VRPH VHFWRUV WR VSHFLDOLVHG
DGMXGLFDWRUV
1.3 The Short-term Insurance Act
7KH$FWKHUHLQDIWHUµ67,$¶GHDOVZLWKVKRUWWHUPSROLFLHVWKDWLQFOXGHDQ
HQJLQHHULQJSROLF\JXDUDQWHHSROLF\OLDELOLW\SROLF\PLVFHOODQHRXVSROLF\
PRWRUSROLF\DFFLGHQWDQGKHDOWKSROLF\SURSHUW\SROLF\RUWUDQVSRUWDWLRQ
SROLF\RUDFRQWUDFWFRPSULVLQJDFRPELQDWLRQRIDQ\RIWKRVHSROLFLHVDQG
LQFOXGHVDFRQWUDFWZKHUHE\DQ\VXFKFRQWUDFWLVUHQHZHGRUYDULHG
7KH$FWSURYLGHVIRUWKHUHJLVWUDWLRQRIVKRUWWHUPLQVXUHUVWKHFRQWURORI
FHUWDLQDFWLYLWLHVRIVKRUWWHUPLQVXUHUVDQGLQWHUPHGLDULHVDQGIRUPDWWHUV
FRQQHFWHG WKHUHZLWK DV VKRUWWHUP LQVXUDQFH EXVLQHVV ZKLFK LQFOXGH
EXVLQHVVDQGDGPLQLVWUDWLYHSUDFWLFHVDQGSROLFLHV¿QDQFLDODUUDQJHPHQWV
MXGLFLDO PDQDJHPHQWDQG ZLQGLQJXS RI LQVXUHUVDQG SUHVFULEHV VSHFL¿F
IHHVWUXFWXUHV7KH$FWDOVRUHJXODWHVDSSURYHGUHLQVXUDQFHSROLFLHV
1.4 Policyholder Protection Rules
&RQVXPHU SURWHFWLRQ PHDVXUHV DUH IXUWKHUPRUH IRXQG LQ 3ROLF\KROGHU
3URWHFWLRQ 5XOHV µ335¶ DUH LVVXHG IURP WLPH WR WLPH LQ WHUPV RI WKH
DERYHPHQWLRQHGDFWV1HZUXOHVEHFDPHRSHUDWLRQDORQ-DQXDU\
7KHVHUXOHVGHDOZLWKREOLJDWRU\DQGVWDQGDUGL]HGGLVFORVXUHVFRQVHTXHQFHV
RI IDLOXUH WR SD\ SUHPLXPV DQG QRQFRPSOLDQFH FDQFHOODWLRQ RI SROLFLHV
FRROLQJRIISHULRGVWKHSUHVFULEHGFRQWHQWVRILQVXUDQFHDJUHHPHQWVDQG
WKHOLNH%RWKWKH/RQJWHUPDQG6KRUWWHUP335IRUH[DPSOHSURKLELWWKH
SDUWLHVIURPDJUHHLQJWRDSUHVFULSWLRQSHULRGRIOHVVWKDQPRQWKV7KH
335DOVRVWDWHWKDWSUHVFULSWLRQPD\RQO\VWDUWUXQQLQJRQFHWKHGD\
WLPHOLPLWDWLRQIRUUHSUHVHQWDWLRQVDVSUHVFULEHGIRUDGLVSXWHGRUUHMHFWHG
FODLPKDYHSDVVHG
6
6HFWLRQRIWKH/7,$
6HHSDUWRIRUH[DPSOHWKH3HQVLRQ)XQGV$GMXGLFDWRU
6HFWLRQ
102
'LVSXWH5HVROXWLRQLQ,QVXUDQFH7KH6RXWK$IULFDQ2PEXG
1.5 The Financial Advisory and Intermediary Services Act
7KLV$FWKHUHLQDIWHUµ)$,6¶UHJXODWHVWKHLQGXVWU\E\FUHDWLQJDUHJXODWRU\
IUDPHZRUN LQ WHUPV RI ZKLFK D ¿QDQFLDO VHUYLFH SURYLGHU DQ LQVXUHU
DFFHSWVUHVSRQVLELOLW\IRUWKHFRQGXFWRIKLVUHSUHVHQWDWLYHV
7KH)$,6$FWFUHDWHVDUHJXODWRU\VWUXFWXUHIRULQWHUPHGLDU\DQGDGYLVRU\
VHUYLFHV SURYLGHG LQ UHVSHFW RI ¿QDQFLDO SURGXFWV $ µ¿QDQFLDO VHUYLFHV
SURYLGHU¶ GHQRWHV DQ\ SHUVRQ RWKHU WKDQ D UHSUHVHQWDWLYH ZKR IXUQLVKHV
DGYLFHRUIXUQLVKHVDGYLFHDQGUHQGHUVDQ\LQWHUPHGLDU\VHUYLFHRUUHQGHUV
DQLQWHUPHGLDU\VHUYLFHDVDUHJXODUIHDWXUHRIKLVEXVLQHVV
7KH$FWUHIHUVWRWKHUHSUHVHQWDWLYHVRI¿QDQFLDOVHUYLFHSURYLGHUVDQGQRW
WRWKHUHSUHVHQWDWLYHVRIFOLHQWV7KHSURYLVLRQVRI3ROLF\KROGHU3URWHFWLRQ
5XOHVIRUERWKWKH/RQJWHUPDQG6KRUWWHUP,QVXUDQFH$FWVVWLOODSSO\
7KH WHUP µDGYLFH¶ LV EURDGO\ GH¿QHG DV µDQ\ UHFRPPHQGDWLRQ JXLGDQFH
RU SURSRVDO RI D ¿QDQFLDO QDWXUH IXUQLVKHG E\ DQ\ PHDQV RU PHGLXP
WR DQ\ FOLHQW RU JURXS RI FOLHQWV¶ ,W PXVW UHODWH WR WKH SXUFKDVH RI DQ\
¿QDQFLDOSURGXFWRUWKHLQYHVWPHQWLQDQ\¿QDQFLDOSURGXFWDQGLQFOXGHV
ORDQ DJUHHPHQWV DQG FHVVLRQV 7KLV H[FOXGHV IDFWXDO DGYLFH JLYHQ RQ
WKH SURFHGXUH WR HQWHU LQWR D WUDQVDFWLRQ UHODWLQJ WR D ¿QDQFLDO SURGXFW
LQ DQVZHU WR URXWLQH TXHULHV WKH GLVSOD\ RU GLVWULEXWLRQ RI SURPRWLRQDO
PDWHULDODQ\DQDO\VLVRUUHSRUWRQD¿QDQFLDOSURGXFWZLWKRXWDQH[SUHVV
RU LPSOLHG UHFRPPHQGDWLRQ JXLGDQFH RU SURSRVDO DGYLFH JLYHQ E\ D
ERDUGRIPDQDJHPHQWRUWUXVWHHVRUERDUGPHPEHURQDQ\SHQVLRQIXQG
RUJDQL]DWLRQIULHQGO\VRFLHW\RUPHGLFDOVFKHPHWRLWVPHPEHUVDQGDQ\
RWKHUH[FOXVLRQVDQQRXQFHGIURPWLPHWRWLPHLQWKH*RYHUQPHQW*D]HWWH
7KHWHUPµLQWHUPHGLDU\VHUYLFH¶LQFOXGHVDQ\DFWRWKHUWKDQWKHIXUQLVKLQJ
RIDGYLFHWKDWLVSHUIRUPHGE\DSHUVRQIRURURQEHKDOIRIDFOLHQWRUD
¿QDQFLDOSURGXFWVXSSOLHUZLWKWKHWKDWUHVXOWWKDWDFOLHQWHQWHUVLQWRRU
RIIHUVWRHQWHULQWRDQ\WUDQVDFWLRQLQUHVSHFWRIVXFKDSURGXFW,WGRHVQRW
LQFOXGHZKHUHDEDQNDFWVPHUHO\DVDFRQGXLWEHWZHHQD¿QDQFLDOVHUYLFH
SURYLGHU DQG D FOLHQW IRU WKH FROOHFWLRQ DQG DFFRXQWLQJ IRU SUHPLXPV RU
RWKHUDPRXQWVGXHE\WKHFOLHQWWRWKHVXSSOLHU
,QDGGLWLRQWRWKHUHJLVWUDWLRQDQGOLFHQVLQJRI¿QDQFLDOVHUYLFHSURYLGHUV
DV GH¿QHG DERYH WKH $FW DOVR IRFXVHV RQ WKH GXWLHV RI ¿QDQFLDO VHUYLFH
SURYLGHUVDQGSURYLGHVIRUFRGHVRIFRQGXFWIRUWKHYDULRXVW\SHVRIVHUYLFH
SURYLGHUV
)$,6SUHVFULEHVVSHFL¿FUXOHVRQFODLPSURFHGXUHVWKHSURFHVVDQGPHWKRGV
RIDVVHVVPHQWDQGGHWHUPLQDWLRQGLVSXWHUHVROXWLRQDQGDSSHDOV
Section 1
3URI%LUJLW.XVFKNH
,W PXVW EH QRWHG WKDW WKHVH VHUYLFHV DOVR IDOO ZLWKLQ WKH VFRSH RI WKH
&RQVXPHU3URWHFWLRQ$FWRI+RZHYHUEHFDXVHLQVXUDQFHGLVSXWH
UHVROXWLRQ PXVW WDNH SODFH LQ DFFRUGDQFH ZLWK WKH GHGLFDWHG LQVXUDQFH
OHJLVODWLRQDQGQRWLQWHUPVRIWKLVJHQHUDOFRQVXPHUSURWHFWLRQVWDWXWH
WKHGLVSXWHUHVROXWLRQSURFHGXUHVIRUFRQVXPHUGLVSXWHVDUHQRWGHDOWZLWK
LQWKLVFRQWULEXWLRQ
2. Dispute Resolution Procedures
2.1 General
7KH IROORZLQJ GLVSXWH UHVROXWLRQ SURFHGXUHV H[LVW ZLWKLQ WKH LQVXUDQFH
LQGXVWU\ LQWHUQDO GLVSXWH UHVROXWLRQ SURFHGXUHV YROXQWDU\ RPEXG
VFKHPHV VWDWXWRU\ RPEXG VFKHPHV VWDWXWRU\ DGMXGLFDWLRQ DUELWUDWLRQ
DQGOLWLJDWLRQ
9ROXQWDU\ VFKHPHV LQFOXGH WKH 2PEXGVPDQ IRU /RQJWHUP ,QVXUDQFH
2PEXGVPDQ IRU 6KRUWWHUP ,QVXUDQFH WKH 2PEXGVPDQ IRU %DQNLQJ
6HUYLFHVDQGWKH&UHGLW,QIRUPDWLRQ2PEXG
6WDWXWRU\ VFKHPHV LQFOXGH WKH 2PEXG IRU )LQDQFLDO 6HUYLFH 3URYLGHUV
3HQVLRQ)XQG$GMXGLFDWRUDQG&RXQFLOIRU0HGLFDO6FKHPHV10
7KHVH SURFHGXUHV VDWLVI\ VHFWLRQ RI WKH &RQVWLWXWLRQ RI WKH 5HSXEOLF
RI 6RXWK $IULFD RQ WKH ULJKW RI DFFHVV WR D FRXUW WULEXQDO RU RWKHU
IRUXP$QDOWHUQDWLYHGLVSXWHUHVROXWLRQVFKHPHSURYLGHVIRUDIDVWHUDQG
PRUH DIIRUGDEOH ZD\ LQ ZKLFK GLVSXWHV LQ WKH LQVXUDQFH LQGXVWU\ FDQ EH
UHVROYHGUDWKHUWKDQIROORZLQJDFRVWO\DQGOHQJWK\OLWLJDWLRQSURFHVVLQWKH
FLYLOFRXUWV'HFLVLRQVDUHEDVHGRQODZDQGHTXLW\ZKLFKDOVRDVVLVWVWKH
LQVXUHGE\LQWURGXFLQJJUHDWHUFRQVXPHUSURWHFWLRQPHDVXUHV
2.2 Regulation of Ombud Schemes
7KH )LQDQFLDO 6HUYLFHV 2PEXG 6FKHPHV $FW11 UHJXODWHV WKHVH VFKHPHV
,QRUGHUWRTXDOLI\IRUUHFRJQLWLRQDVDVFKHPHLWPXVWFRPSO\ZLWKWKH
IROORZLQJUHTXLUHPHQWV12
DDPDMRULW\RI¿QDQFLDOLQVWLWXWLRQVEDVHGRQDVVHWYDOXHJURVVLQFRPH
RUFOLHQWEDVHDVWKH&RXQFLOPD\GHWHUPLQHLQJHQHUDORULQDSDUWLFXODU
LQVWDQFHLQDSDUWLFXODUFDWHJRU\RI¿QDQFLDOLQVWLWXWLRQVPXVWSDUWLFLSDWH
LQWKHVFKHPH
E D ERG\ WKDW LV QRW FRQWUROOHG E\ SDUWLFLSDQWV LQ WKH VFKHPH DQG WR
10
)RUDFRQFLVHVXPPDU\RIWKHVWUXFWXUHRIWKHVHRPEXGVFKHPHVVHH0LOODUG'Modern
Insurance Law in South Africa FKDSWHU
11
$FWRI
12
6HFWLRQ
104
ZKLFK WKH RPEXG LV DFFRXQWDEOH PXVW L DSSRLQW WKH RPEXG VHWWOH
WKHUHPXQHUDWLRQDQGPRQLWRUWKHSHUIRUPDQFHDQGLQGHSHQGHQFHRIWKH
RPEXGDQGLLPRQLWRUWKHFRQWLQXHGFRPSOLDQFHE\WKHVFKHPHZLWKLWV
FRQVWLWXWLRQWKHSURYLVLRQVRIWKHVFKHPHDQGWKLV$FWDQGUHSRUWDQ\QRQ
FRPSOLDQFHWRWKH&RXQFLO
F WKH VFKHPH PXVW SURYLGH IRU PLQLPXP UHTXLUHPHQWV UHODWLQJ WR
TXDOL¿FDWLRQV FRPSHWHQFH NQRZOHGJH DQG H[SHULHQFH ZLWK ZKLFK WKH
RPEXGPXVWFRPSO\
G WKH VFKHPH PXVW KDYH VXI¿FLHQW KXPDQ ¿QDQFLDO DQG RSHUDWLRQDO
UHVRXUFHVDQGEHIXQGHGE\WKHSDUWLFLSDQWVLQWKHVFKHPHWRHQDEOHWKH
RPEXGWRIXQFWLRQHI¿FLHQWO\DQGWLPHRXVO\
HWKHSURSRVHGSURFHGXUHVRIWKHVFKHPHPXVWHQDEOHWKHRPEXG
LWRUHVROYHDFRPSODLQWWKURXJKPHGLDWLRQFRQFLOLDWLRQ
UHFRPPHQGDWLRQ
LLWRDFWLQGHSHQGHQWO\LQUHVROYLQJDFRPSODLQWRULQPDNLQJD
GHWHUPLQDWLRQ
LLLWRIROORZLQIRUPDOIDLUDQGFRVWHIIHFWLYHSURFHGXUHV
LYZKHUHDSSURSULDWHWRDSSO\SULQFLSOHVRIHTXLW\LQUHVROYLQJD
FRPSODLQW
YWRUHSRUWWRWKHUHJLVWUDUDQGWRDERG\UHSUHVHQWDWLYHRIWKH
UHOHYDQWFDWHJRU\RI¿QDQFLDOLQVWLWXWLRQVRQPDWWHUVZKLFKPD\EHRI
LQWHUHVWWRWKHP
ISURYLVLRQPXVWEHPDGHIRUWKHHIIHFWLYHHQIRUFHPHQWRIGHWHUPLQDWLRQV
RIWKH2PEXG
J SURYLVLRQ PXVW EH PDGH WR HQVXUH WKDW WKH TXHVWLRQV FRQFHUQV DQG
FRPSODLQWVRIFRQVXPHUVDUHWUHDWHGHTXLWDEO\DQGFRQVLVWHQWO\LQDWLPHO\
HI¿FLHQWDQGFRXUWHRXVPDQQHU
KWKHVFKHPHPXVWSURYLGHIRUZD\VLQZKLFKLWZLOOFRRSHUDWHZLWKWKH
&RXQFLO¶VIXQFWLRQVRISURPRWLQJWKHHGXFDWLRQRIFOLHQWVDQGFRRUGLQDWLQJ
WKHDFWLYLWLHVFRQWHPSODWHGLQVHFWLRQOFDQG
L DQ\ RWKHU UHTXLUHPHQWV WKDW PD\ EH SUHVFULEHG DQG WKDW DUH QRW LQ
FRQÀLFWZLWKWKHDLPVDQGREMHFWVRIWKLV$FW
$ VFKHPH PXVW VXEPLW LWV DSSOLFDWLRQ IRU UHFRJQLWLRQ LQ WKH SUHVFULEHG
PDQQHUDQGIRUPWRWKH&RXQFLO
6HFWLRQ
3URI%LUJLW.XVFKNH
2.3 Internal dispute resolution schemes:
,QVXUDQFHGLVSXWHVEHWZHHQLQVXUHUVDQGLQVXUHGVPD\EHVROYHGE\LQWHUQDO
FRPSODLQWUHVROXWLRQSURFHGXUHVDVDJUHHGXSRQEHWZHHQWKHLQVXUHUDQG
WKHLQVXUHG$QLQVXUHGPXVW¿UVWH[KDXVWWKHVHVFKHPHVEHIRUHKHPD\
UHIHUWKHGLVSXWHIRUUHVROXWLRQXQGHUDQRWKHUVFKHPHVXFKDVWKHRPEXG
RUWRDGMXGLFDWLRQRUOLWLJDWLRQ
$OOSROLFLHVGRQRWKDYHWREHLQZULWLQJ,QVXUHUVPXVWKRZHYHUZLWKLQD
UHDVRQDEOHSHULRGIURPGDWHRIFRQWUDFWLQIRUPDSROLF\KROGHULQZULWLQJRI
GHWDLOV RI DQ\ LQWHUQDO FRPSODLQW UHVROXWLRQ V\VWHPV DQG SURFHGXUHV DV
ZHOODVIXOOSDUWLFXODUVUHODWLQJWRWKH,QVXUDQFH2PEXGVFKHPHV
$QLQVXUHUPXVWDFFHSWUHMHFWRUGLVSXWHDFODLPZLWKLQDUHDVRQDEOHSHULRG
DIWHUUHFHLYLQJWKHFODLPDQGWKHQQRWLI\WKHSROLF\KROGHULQZULWLQJRIKLV
GHFLVLRQZLWKLQGD\VRIWDNLQJWKHGHFLVLRQ
:KHUHDQLQVXUHUUHMHFWVDFODLPRUGLVSXWHVWKHTXDQWXPRIWKHEHQH¿W
FODLPHG KH PXVW LQIRUP WKH SROLF\KROGHU LQ WKH ZULWWHQ QRWL¿FDWLRQ RI
LWKHUHDVRQVIRUKLVGHFLVLRQLLWKDWWKHSROLF\KROGHUKDVDSHULRGRI
QRWOHVVWKDQGD\VIURPGDWHRIUHFHLSWRIVXFKDQRWL¿FDWLRQWRPDNH
UHSUHVHQWDWLRQVWRWKHLQVXUHULQUHVSHFWRIWKHODWWHU¶VGHFLVLRQLLLWKH
ULJKW RI WKH SROLF\KROGHU WR ORGJH D FRPSODLQW LQ WHUPV RI WKH DQG WKH
UHOHYDQWSURYLVLRQVRIWKH)LQDQFLDO6HUYLFHV2PEXG6FKHPHV$FWLQSODLQ
XQGHUVWDQGDEOHODQJXDJHLYDQ\WLPHOLPLWDWLRQSURYLVLRQIRULQVWLWXWLQJ
OHJDODFWLRQDQGWKHLPSOLFDWLRQVWKHUHRILQDQHDVLO\XQGHUVWRRGPDQQHU
DQGYZKHUHWKHSROLF\GRHVQRWFRQWDLQDWLPHOLPLWDWLRQWKHSUHVFULSWLRQ
SHULRGWKDWZLOODSSO\LQWHUPVRIWKH3UHVFULSWLRQ$FW14DWWKHPRPHQWD
SUHVFULSWLRQSHULRGRI\HDUVDSSOLHVDQGWKHLPSOLFDWLRQVWKHUHRILQDQ
HDVLO\XQGHUVWRRGPDQQHU
7KHLQVXUHUPXVWWKHQZLWKLQGD\VRIUHFHLSWRIVXFKDUHSUHVHQWDWLRQ
QRWLI\WKHSROLF\KROGHULQZULWLQJRIKLVGHFLVLRQWRDFFHSWUHMHFWRUGLVSXWH
WKHFODLP7KLVQRWL¿FDWLRQPXVWFRQWDLQUHDVRQVIRUWKHGHFLVLRQWKHIDFWV
WKDWLQIRUPHGWKHGHFLVLRQDQGLLLWRYLQEDERYHZKHUHWKHFODLPLV
UHMHFWHGRUGLVSXWHG
'HVSLWHDQ\DJUHHPHQWRQDWLPHOLPLWDWLRQDSROLF\KROGHUPD\UHTXHVW
WKH FRXUW WR FRQGRQH QRQFRPSOLDQFH ZKHUH JRRG FDXVH H[LVWV IRU WKH
IDLOXUHDQGZKHUHWKHFODXVHLVXQIDLUWRWKHSROLF\KROGHU
'XULQJ D GLVSXWH UHVROXWLRQ WKH 6KRUWWHUP 335 SURKLELWV FODXVHV RQ
SRO\JUDSKOLHGHWHFWRUDQGWUXWKYHUL¿FDWLRQSURFHGXUHV$Q\FODXVHLQD
SROLF\WKDWDQ\GLVSXWHXQGHUWKHSROLF\FDQRQO\EHUHVROYHGE\DUELWUDWLRQ
LVDOVRSURKLELWHG
14
$FWRI
106
3. Voluntary Ombud schemes
3.1 Voluntary Schemes for insurance disputes
:KHUHDGLVSXWHFRQWLQXHVWRH[LVWEHWZHHQDQLQVXUHUDQGDQLQVXUHGWKH
SDUWLHVPD\WKHQUHIHUWKHGLVSXWHIRUUHVROXWLRQWRWKHYROXQWDU\VFKHPHV
FUHDWHG E\ LQVXUHUV QDPHO\ WKH 2PEXGVPDQ IRU /RQJWHUP ,QVXUDQFH
WKH2PEXGVPDQIRU6KRUWWHUP,QVXUDQFH7KHVHYROXQWDU\RPEXGVPHQ
DUHIXQGHGDQGUHJXODWHGE\WKHLQGXVWU\WRVHUYHDVDIRUPRIVWUXFWXUHG
GLVSXWHUHVROXWLRQDOWHUQDWLYHWROLWLJDWLRQ7KHSDUWLHVWRWKHGLVSXWHDJUHH
WREHERXQGE\WKHGHFLVLRQRIWKHRPEXG
6RPHRIWKHEHQH¿WVWKDWWKHRPEXGVFKHPHRIIHUVDUHLQIRUPDOLW\RIWKH
SURFHVVUHDG\DFFHVVWRDGLVSXWHUHVROXWLRQSURFHGXUHFRVWHIIHFWLYHQHVV
VSHHG\UHVROXWLRQRIGLVSXWHVPHGLDWLRQUDWKHUWKDQDGMXGLFDWLRQDQGWKH
ULJKWWRDIIRUGGXHZHLJKWWRHTXLW\
3.2 The Short-term Ombud
3.2.1 Structure of the Ombud
7KH2I¿FHRIWKH2PEXGVPDQIRU6KRUW7HUP,QVXUDQFHLVDFRPSDQ\QRW
IRU SUR¿W DQG LV DFFRXQWDEOH WR LWV ERDUG RI GLUHFWRUV ,W LV D YROXQWDU\
VFKHPH WKDW KDV EHHQ JUDQWHG UHFRJQLWLRQ LQ WHUPV RI WKH SURYLVLRQV RI
WKH)LQDQFLDO6HUYLFHV2PEXG6FKHPHV$FW)RXQGHGLQ$XJXVWWKH
2I¿FH RI WKH 2PEXGVPDQ IRU 6KRUW7HUP ,QVXUDQFH SURYLGHV FRQVXPHUV
ZLWK D IUHH HI¿FLHQW DQG IDLU GLVSXWH UHVROXWLRQ PHFKDQLVP ,W RIIHUV
FRQVXPHUVZLWKD³QRULVN´PHFKDQLVPWRUHVROYHGLVSXWHVZLWKLQVXUHUV
$OO SHUVRQDO OLQHV VKRUWWHUP LQVXUHUV DV ZHOO DV /OR\G¶V KDYH DJUHHG WR
DELGHE\WKH2PEXGVPDQ¶VMXULVGLFWLRQDQGGHFLVLRQV
7KH2I¿FHFDQDVVLVWFRQVXPHUVZLWKSHUVRQDOOLQHVVKRUWWHUPLQVXUDQFH
GLVSXWHVXFKDVPRWRUKRXVHRZQHUVEXLOGLQJVKRXVHKROGHUVFRQWHQWV
PRYDEOHDVVHWWUDYHOGLVDELOLW\FUHGLWSURWHFWLRQLQVXUDQFHDQGFRPPHUFLDO
LQVXUDQFH RQ D OLPLWHG EDVLV LH FODLPDQWV VXFK DV VPDOO EXVLQHVVHV
LQFOXGLQJDVROHSURSULHWRURUWUDGHUDMXULVWLFSHUVRQSDUWQHUVKLSRUWUXVW
WKDWKDVDWXUQRYHULQWKHODVW¿QDQFLDO\HDURIOHVVWKDQ5PLOOLRQ7KH
VHUYLFHLVIUHHRIFKDUJH
3.2.2 Procedure and determination
$ FRPSODLQDQW PXVW ¿UVW H[KDXVW LQWHUQDO FRPSODLQW PHFKDQLVPV EHIRUH
ORGJLQJ KLV FRPSODLQW ZLWK WKH 2PEXG :KHUH OHJDO SURFHHGLQJV KDYH
FRPPHQFHG D FODLP FDQQRW EH GHWHUPLQHG E\ WKH 2PEXG 7KH WZR
SURFHGXUHVFDQQRWUXQVLPXOWDQHRXVO\
7KH2PEXGVPDQ¶VWDVNLVWRDFWDVDQLQGHSHQGHQWDQGREMHFWLYH³PHGLDWRU´
6HHIRRWQRWHDERYH
3URI%LUJLW.XVFKNH
RULQIRUPDODUELWUDWRUDQGKHVKHGRHVQRWUHSUHVHQWHLWKHURIWKHSDUWLHV
WRWKHGLVSXWH
7KH 2PEXG LV QRW XQGHU LQVWUXFWLRQV RI DQ\RQH ZKHQ H[HUFLVLQJ KLV
DXWKRULW\WRPDNHDUXOLQJ7KH2PEXGUHVROYHVGLVSXWHVDIWHUHVWDEOLVKLQJ
DOO PDWHULDO IDFWV DQG E\ DSSO\LQJ FULWHULD RI ODZ HTXLW\ DQG IDLUQHVV $
ZULWWHQGLUHFWLYHLVLVVXHGZKLFKLVELQGLQJRQWKHLQVXUDQFHFRPSDQ\EXW
QRWLQWKHFRPSODLQDQW
7KH FRPSODLQDQW ZKR ZLVKHV WR DSSHDO WKH GHFLVLRQ PD\ HVFDODWH WKH
GLVSXWHUHVROXWLRQWRDQRWKHUSURFHGXUHVXFKDVDUELWUDWLRQRUDSSURDFKD
FRXUWRIODZ
3.3 The Long-term Ombud
3.3.1 Structure of the Ombud
7KHRI¿FHIRUWKH2PEXGVPDQIRU/RQJWHUP,QVXUDQFHZDVHVWDEOLVKHGLQ
DQGKDVDOVREHHQJUDQWHGUHFRJQLWLRQLQWHUPVRIWKHSURYLVLRQVRI
WKH)LQDQFLDO6HUYLFHV2PEXG6FKHPHV$FW,WLVDYROXQWDU\DVVRFLDWLRQ
QRWIRUJDLQWKDWLQLWLDOO\VWDUWHGDVDIRUPRIVHOIUHJXODWLRQE\VXEVFULELQJ
LQVXUHUVZKRGHYHORSHGWKHLURZQUXOHVDQGSURFHGXUHVRYHUWLPH1RWDOO
LQVXUHUVDUHPHPEHUV,WUHPDLQVDQLQGHSHQGHQWRI¿FHWKDWLVDFFRXQWDEOH
WRDQLQGHSHQGHQW/RQJWHUP2PEXGVPDQ&RXQFLOIRUSURYLGLQJDQHI¿FLHQW
DQGLQGHSHQGHQWVHUYLFHWRSROLF\KROGHUVDQGRWKHUVLQUHVSRQVHWRGLVSXWHV
DULVLQJIURPORQJWHUPLQVXUDQFHSROLFLHV
7KH IXQFWLRQ RI WKH 2PEXG RI¿FH LV WR PHGLDWH LQ GLVSXWHV EHWZHHQ
VXEVFULELQJPHPEHUVRIWKHORQJWHUPLQVXUDQFHLQGXVWU\DQGSROLF\KROGHUV
VXFFHVVRUVLQWLWOH EHQH¿FLDULHV WKH SHUVRQ ZKRVH OLIH LV LQVXUHG D
SUHPLXP SD\HU RU DQ\ SHUVRQ UHSUHVHQWLQJ DQ\ RI WKHVH SHUVRQV 7KLV
VHUYLFHLVDOVRIUHHWRFRPSODLQDQWV
3.3.2 Procedure and determination
&RPSODLQDQWV ZKR VXEPLW D FRPSODLQW WR WKH 2PEXGVPDQ PD\ VWLOO
GHFLGHWRIROORZWKHFRQYHQWLRQDOFLYLOMXVWLFHSURFHVVDOWKRXJKWKHVHWZR
SURFHVVHV DUH QRW DOORZHG WR SURFHHG VLPXOWDQHRXVO\ 7KH 2PEXG PD\
DOVR QRW GHWHUPLQH D GLVSXWH ZKHUH D SUHYLRXV 2PEXG UXOLQJ KDV EHHQ
PDGHZKHUHWKHGLVSXWHLVVXEMHFWWRSDVWSHQGLQJRUFRQWHPSODWHGOHJDO
SURFHHGLQJV RU ZKHUH WKH FODLP KDV SUHVFULEHG :KHUH WKH 2PEXG PD\
GHFOLQHWRKDQGOHDFRPSODLQWZKHUHIRUH[DPSOHWKHUHDSSHDUVWREHOLWWOH
FKDQFHRIVXFFHVVLVEHWWHUGHDOWZLWKE\DFRXUWRIODZRUZKHUHQRORVV
RULQFRQYHQLHQFHLVVXIIHUHG
7KH 2PEXG PD\ UHIHU WKH GLVSXWH WR DQ DVVHVVRU RU WR DQ DGMXGLFDWRU
ZKHUH WKH LVVXH EHIRUH LW LV FRPSOH[ DQG D VLPSOH GHWHUPLQDWLRQ E\ WKH
2PEXGLVQRWSRVVLEOH
,QGXVWU\VXEVFULEHUVDUHERXQGE\WKH2PEXGVPDQ¶VUXOLQJV&RPSODLQDQWV
DUHKRZHYHUQRWERXQGDQGPD\WDNHOHJDOUHFRXUVHWRDQRWKHUIRUXPVXFK
DVDUELWUDWLRQRUFRPPHQFHZLWKOLWLJDWLRQ
3.3.3 Appeals
7KHUHLVSURYLVLRQLQWKHUXOHVIRUDQLQIRUPDODSSHDOSURFHVVSURYLGHGWKDW
WKH2PEXGDJUHHVWRJUDQWOHDYHWRDSSHDO$SSOLFDWLRQIRUOHDYHWRDSSHDO
PXVWEHPDGHZLWKLQRQHPRQWKIURPWKH¿QDOGHWHUPLQDWLRQ7KHDSSHDOLV
KHDUGE\DWULEXQDODVSURSRVHGE\WKH2PEXGDQGDJUHHGWRE\DOOSDUWLHV
7KHGHWHUPLQDWLRQE\WKHWULEXQDOLVELQGLQJXSRQWKHLQVXUHU:KHUHWKH
FRPSODLQDQWLVWKHDSSHOODQWDQGORVHVWKHWULEXQDOGHWHUPLQDWLRQLVELQGLQJ
XSRQWKHFODLPDQWDVZHOO+RZHYHUZKHUHWKHLQVXUHULVWKHDSSHOODQWDQG
WKHDSSHDOGHWHUPLQDWLRQLVLQKLVIDYRXUWKHFODLPDQWPD\WKHQVWLOOWDNH
OHJDOUHFRXUVHE\UHIHUULQJWKHPDWWHUWRDQRWKHUIRUXPRUFRQWLQXHZLWK
OLWLJDWLRQ
,QFRQWUDVWWRWKHUXOLQJVRIWKH)$,62PEXGWKHUXOLQJVRIWKH/RQJWHUP
2PEXG GR QRW FUHDWH SUHFHGHQWV 7KH ODWWHU DUH PDGH RQ SULQFLSOHV RI
IDLUQHVVDQGHTXLW\
4. Statutory Schemes
7KH2I¿FHRIWKH)LQDQFLDO$GYLVRU\DQG,QWHUPHGLDU\
Services Ombud
,QGLVSXWHVZKHUHDGYLVRUVEURNHUVDQGLQWHUPHGLDULHVDUHLQYROYHGWKH
GLVSXWH UHVROXWLRQ SURFHVV UHVRUWV XQGHU WKH MXULVGLFWLRQ RI WKH 2I¿FH RI
WKH 2PEXG IRU )LQDQFLDO 6HUYLFH 3URYLGHUV WKH µ)$,6 2PEXG¶ 7KLV LV D
VWDWXWRU\RPEXGVPDQVFKHPHDVUHJXODWHGE\WKH)LQDQFLDO6HUYLFHV2PEXG
6FKHPHV$FW167KH$FWSUHVFULEHVWKHFODLPSURFHGXUHVWKHSURFHVVDQG
PHWKRGV RI DVVHVVPHQW DQG GHWHUPLQDWLRQ DQG DSSHDOV LQ WKH 5XOHV RQ
3URFHHGLQJVRIWKH2I¿FHRIWKH2PEXGIRU)LQDQFLDO6HUYLFH3URYLGHUV
$ GLVSXWH EHWZHHQ D FOLHQW DQG D ¿QDQFLDO VHUYLFH SURYLGHU RU RQH RI LWV
UHSUHVHQWDWLYHV PXVW ¿UVW H[KDXVW WKH LQWHUQDO FRPSODLQW UHVROXWLRQ
V\VWHPDQGSURFHGXUHVRIWKHSURYLGHU
:KHUHLWUHPDLQVXQUHVROYHGDIWHUDSHULRGRIVL[ZHHNVKDVH[SLUHGIURP
GDWHRIUHIHUUDOWRWKHUHVSRQGHQWWKH)$,62PEXGPD\DGMXGLFDWHWKH
16
$FWRI
SURPXOJDWHGLQWHUPVRIVHFWLRQRIWKH)$,6$FW
3DUW ;, RI WKH *HQHUDO &RGH RI &RQGXFW IRU $XWKRULVHG )LQDQFLDO 6HUYLFH 3URYLGHUV DQG
5HSUHVHQWDWLYHV
5XOHDLYRIWKH2PEXG5XOHV
3URI%LUJLW.XVFKNH
PDWWHU$FRPSODLQDQWPD\GHFLGHWRUHIHUWKHPDWWHUWRWKH2PEXGRUPD\
DVDQDOWHUQDWLYHDJUHHWRDUELWUDWLRQRULQDOOFDVHVDSSURDFKWKHFRXUW
,QVXUHUVZKRZLVKWRDGGUHVVDGLVSXWHIRUUHVROXWLRQPXVWKRZHYHUUHIHU
WKHPDWWHUWRWKH)$,62PEXG
$Q\IRUPRIUHOLHIPD\EHVRXJKW$FRPSODLQDQWPD\VHHNDQDZDUGRIDQ
DPRXQWRIPRQH\DVUHGUHVVIRU¿QDQFLDOSUHMXGLFHRUGDPDJHVXIIHUHG$
MXULVGLFWLRQDOOLPLWRI5LVSODFHGRQDQDZDUGRIWKLVQDWXUH20
4.2 Special adjudicators
,QVRPHDUHDVVSHFLDODGMXGLFDWRUVKDYHEHHQDSSRLQWHGLQWKHLQVXUDQFH
LQGXVWU\ WR GHDO ZLWK VSHFLDOLVHG LQVXUDQFH LVVXHV 7KH 3HQVLRQ )XQGV
$GMXGLFDWRU VHUYHV DV DQ H[DPSOH21 7KH &RXQFLO IRU 0HGLFDO 6FKHPHV
KDVLWVRZQFRPSODLQWSURFHGXUHDQGSURYLGHVIRUVXEPLVVLRQRIGLVSXWHV
UHJDUGLQJPHGLFDODLGFODLPVWRWKH5HJLVWUDU¶V2I¿FH22:KHUHKRZHYHU
WKHFRPSODLQWLVSHUWDLQLQJWRWKHFRQGXFWRIDEURNHUWKH)$,62PEXGKDV
MXULVGLFWLRQDQGZKHUHLWUHODWHVWRKHDOWKLQVXUDQFHSURGXFWVWKHUHOHYDQW
LQVXUDQFHRPEXGVKRXOGEHDSSURDFKHG$VWKLVLVQRWDQ2PEXGVFKHPH
LQ WKH WUXH VHQVH RI WKH ZRUG DQG DV LW LV UHJXODWHG E\ VWDWXWH D ORQJ
GLVFXVVLRQRQWKHSURFHVVLVRPLWWHGIURPWKLVDUWLFOH
5. The FAIS Ombud claims procedure and determination
5.1 Procedure and determination
7KH SUHVFULEHG &RPSODLQW 5HJLVWUDWLRQ )RUP PXVW EH FRPSOHWHG DQG WKH
FODLP VXEPLWWHG WR WKH 2PEXG 2I¿FH $ FODLP FDQQRW EH KHDUG E\ WKH
2PEXGLILWKDVSUHVFULEHG 2QFHWKHFODLPKDVEHHQDVVHVVHGUHJLVWHUHG
DQGIRXQGWREHMXVWLFLDEOHWKHFRPSODLQWIROORZVWKUHHVWDJHVWKHLQLWLDO
WKHLQYHVWLJDWLYHDQG¿QDOO\WKHDGMXGLFDWLYHVWDJH24
7KH 2PEXG PD\ IROORZ DQG LPSOHPHQW DQ\ SURFHGXUH ZKLFK LQFOXGHV
FRQFLOLDWLRQ DQG PHGLDWLRQ WR DWWHPSW D VHWWOHPHQW E\ WKH SDUWLHV
,W PD\ DOORZ DQ\ SDUW\ WKH ULJKW RI OHJDO UHSUHVHQWDWLRQ ,W PD\ PDNH
UHFRPPHQGDWLRQV WR WKH SDUWLHV 6KRXOG DQ\ SDUW\ UHMHFW WKH 2PEXG
UHFRPPHQGDWLRQKHPD\SURFHHGWRGHWHUPLQHWKHPDWWHU
,QWKHGHWHUPLQDWLRQWKH2PEXGKDVZLGHUDQJLQJSRZHUVDWKHFRPSODLQW
20
,WPD\EHPHQWLRQHGWKDWWKHMXULVGLFWLRQRIWKHORZHUFRXUWVRUPDJLVWUDWHVFRXUWVDUHIDU
ORZHUDQGDFODLPRIWKLVQDWXUHEURXJKWEHIRUHWKH)$,62PEXGZLOOSURYLGHDQREYLRXV
DGYDQWDJHWRWKHLQVXUHGDVFRPSODLQDQW
21
3HQVLRQ)XQGV$FWRIVHFWLRQ
22
0HGLFDO6FKHPHV$FWRIVHFWLRQ
6HHSDUDERYHRQWKH\HDUSUHVFULSWLRQSHULRG
24
6HFWLRQRIWKH)$,6$FW
110
PD\ EH GLVPLVVHG E XSKROG WKH FRPSODLQW ZKROO\ RU RQO\ SDUWLDOO\ F
DZDUG DQ DPRXQW RI PRQH\ WR SURYLGH UHGUHVV IRU ¿QDQFLDO GDPDJH RU
SUHMXGLFH G LVVXH D GLUHFWLRQ WKDW DQ\ SDUW\ PXVW WDNH WKH QHFHVVDU\
VWHSV DV WKH 2PEXG PD\ GHHP DSSURSULDWH DQG MXVW IRU SXUSRVHV RI KLV
GHWHUPLQDWLRQHPDNHDQ\RUGHUWKDWDFRXUWRIODZFRXOGPDNHZKLFK
LQFOXGHVDQRUGHUIRUSD\PHQWRILQWHUHVWIPDNHDQRUGHUDVWRFRVWV
,QFRQWUDVWWRWKHYROXQWDU\RPEXGVFKHPHVWKHUXOLQJVRIWKH)$,62PEXG
GR FUHDWH SUHFHGHQWV ZKHUH LW LV SRVVLEOH WR HQIRUFH WKH GHWHUPLQDWLRQ
DV VXFK LQ RWKHU FDVHV 'HWHUPLQDWLRQV EDVHG RQ WKH FULWHULD RI IDLUQHVV
GHSHQGLQJRQWKHVSHFL¿FIDFWVDQGFLUFXPVWDQFHVPLJKWQRWEHVXLWDEOH
IRUVXEVHTXHQWJHQHUDOHQIRUFHPHQW
5.2 Appeals
$Q\SDUW\PD\DSSO\LQZULWLQJIRUOHDYHWRDSSHDOZLWKLQRQHPRQWKIURP
WKHGDWHRIWKH2PEXGGHWHUPLQDWLRQ7KH2PEXGPD\GHFLGHWRUHIXVHRU
DOORZWKHDSSHDOGHSHQGLQJRQZKHWKHULWLVRIWKHRSLQLRQWKDWWKH%RDUG
RI$SSHDOZRXOGFKDQJHWKHRULJLQDOGHWHUPLQDWLRQ
:KHUH WKH 2PEXG UHIXVHV WKH UHTXHVW IRU OHDYH WR DSSHDO WKH %RDUG RI
$SSHDOPD\EHSHWLWLRQHGGLUHFWO\IRUOHDYHWRDSSHDOSURYLGHGWKDWLWLV
ZLWKLQRQHPRQWKIURPGDWHRIWKHUHIXVDORIWKH2PEXGWRDOORZOHDYHWR
DSSHDO
7KH%RDUGRI$SSHDOPD\KHDUWKHDSSHDOZLWKRUZLWKRXWWKHSDUWLFLSDWLRQ
RIWKH2PEXG7KHGHFLVLRQRIWKH%RDUGLV¿QDODQGELQGLQJ
7KHFRPSODLQDQWPD\QRWWDNHWKHPDWWHUWRFRXUWZKHUHKHKDVFKRVHQWR
IROORZWKH)$,62PEXGURXWHIRUGLVSXWHUHVROXWLRQ
6. Conclusion
$FRPSODLQDQWLVQRWREOLJHGWRDSSURDFKDQ\2PEXGIRUWKHGHWHUPLQDWLRQ
RIDOOGLVSXWHV7KHFRPSODLQDQWFDQHOHFWWRSDUWLFLSDWHLQWKHYROXQWDU\
VFKHPHV ZKHUH VXLWDEOH RU WR DSSURDFK D FRXUW RI ODZ RU WR UHIHU WKH
PDWWHU WR DUELWUDWLRQ 2QFH D FRPSODLQDQW KDV FKRVHQ KLV IRUXP KH LV
ERXQGWRSXUVXHWKHPDWWHUZLWKLQWKHUXOHVDQGSURFHGXUHVRIWKHVXLWDEOH
IRUXP:KHUHKRZHYHUWKHPDWWHUKDVWREHKHDUGE\DVWDWXWRU\VFKHPH
VXFKDVWKH)$,62PEXGWKHFRPSODLQDQWPXVWDGKHUHWRWKHSURFHGXUHV
DQGUXOHVFUHDWHGE\VWDWXWH:KHUHDVSHFL¿FVHFWLRQRIWKHLQGXVWU\KDV
D VSHFLDOLVW VWDWXWRU\ DGMXGLFDWRU WKH FRPSODLQDQW KDV QR FKRLFH EXW WR
IROORZWKHDGMXGLFDWLRQSURFHGXUHDFFRUGLQJWRLWVUXOHVDQGSURFHGXUHV$V
WKHODWWHULVQRWDIRUPDO2PEXGVFKHPHLWKDVQRWEHHQLQFRUSRUDWHGLQ
JUHDWGHWDLOLQWKHGLVFXVVLRQDERYH
111
Turkish Special Arbitration Scheme
for Claims Against Insurers
Dr. Samim Ünan
AIDA Turkey
6DPLPhQDQZDVERUQLQ$QNDUD7XUNH\LQ+HWHDFKHVWUDQVSRUWODZDQGLQVXUDQFH
law at the University of Galatasaray. He works as legal consultant for insurance companies.
6DPLPLVWKHSDVWSUHVLGHQWRIWKH7XUNLVK,QVXUDQFH/DZ$VVRFLDWLRQ7,/$ 7XUNLVK
$,'$EHWZHHQDQGWKHLPPHGLDWH3DVW3UHVLGHQWRIWKH7XUNLVK0DULWLPH
/DZ$VVRFLDWLRQ+HLVFXUUHQWO\$,'$3UHVLGHQWLDO&RXQFLO0HPEHU$,'$6FLHQWLÀF
&RXQFLO0HPEHUDQG$,'$&RQVXPHU3URWHFWLRQ'LVSXWH5HVROXWLRQ:RUNLQJ3DUW\
Chairman.
3ROLF\KROGHUVH[SHFWWKDWWKHLQVXUHUVSD\SURPSWO\DQGZLWKRXWVKRUWDJH
%XW VRPHWLPHV LQVXUHUV UHIXVH WR HIIHFW SD\PHQW DQG WKH SROLF\KROGHUV
KDYH WR DSSO\ IRU UHGUHVV ,Q PDQ\ FRXQWULHV WKH QHHG WR SURWHFW WKH
SROLF\KROGHUV DW OHDVW WKH FRQVXPHUV DJDLQVW LQVXUHUV KDV SXVKHG WKH
/HJLVODWRUVRUWKHLQVXUDQFHVHFWRURUWKH5HJXODWRUWRLPSOHPHQWGLIIHUHQW
VROXWLRQV
7XUNLVKOHJLVODWRUXSRQLQLWLDWLYHDQGLQLWLDOSUHSDUDWRU\ZRUNRIWKH7XUNLVK
5HJXODWRUKDVHQDFWHGVSHFLDOUXOHVWRFUHDWHDVSHFLDODUELWUDWLRQVFKHPH
IRUFODLPVDJDLQVWWKHLQVXUHUVDULVLQJRXWRILQVXUDQFHFRQWUDFWV
:HZLOOH[DPLQHEHORZWKHPDLQSRLQWVRIWKLVVSHFLDOVFKHPH
Dispute resolution methods
,Q7XUNH\WKHSULQFLSDOGLVSXWHUHVROXWLRQPHWKRGVUHJDUGLQJWKHLQVXUDQFH
DUH³FRPSODLQWV´DQG³OHJDODFWLRQV´
Complaints
9HU\ RIWHQ WKH SROLF\KROGHU RU WKH LQVXUHG ZLOO XSRQ XQZLOOLQJQHVV RI WKH
LQVXUHUWRSD\WKHLQVXUDQFHPRQH\IRUPXODWHDFRPSODLQWKRSLQJUHGUHVV
Insurance Intermediary
,W LV QRW UDUH WKDW WKH SROLF\KROGHUVLQVXUHG IRUPXODWH WKHLU FRPSODLQW
DW ¿UVW JODQFH WR WKH LQVXUDQFH LQWHUPHGLDU\ LQ WKH H[SHFWDWLRQ WKDW WKH
LQWHUPHGLDU\ ZLOO SXW SUHVVXUH RQ WKH LQVXUHU 1RW RQO\ EURNHUV ZKR DUH
112
7XUNLVK6SHFLDO$UELWUDWLRQ6FKHPHIRU&ODLPV$JDLQVW,QVXUHUV
DSSRLQWHG E\ WKH SROLF\KROGHUV EXW DOVR LQVXUDQFH DJHQWV ZKR RZH D
OHJDOGXW\RIOR\DOW\WRWKHLQVXUHUUHJXODUO\LQWHUIHUHDQGWU\WRFRQYLQFH
WKH LQVXUHU WR SD\ RU WR HDVH WKH SURFHVV WKDW PLJKW OHDG WR SD\PHQW
7KHLQVXUDQFHDJHQWZLOO FRQVLGHUWKDWDIWHUDOOWKHSROLF\KROGHUEHLQJD
FRPSRQHQWRILWVSRUWIROLRGHVHUYHVVSHFLDOVXSSRUWGHVSLWHWKHIDFWWKDW
VXFKLQLWLDWLYHRIWHQFUHDWHVDFRQÀLFWZLWKLWVOHJDOGXWLHV
Insurance Undertaking
,QVXUHUVHVWDEOLVKLQDFFRUGDQFHZLWKOHJDOUHTXLUHPHQWVVSHFLDOVHUYLFHVIRU
FRPSODLQWV7KHSHUVRQZKRZLOOGHDOZLWKWKHFRPSODLQWPXVWEHGLIIHUHQW
IURP WKH RQH ZKR UHMHFWHG WKH FODLP +RZHYHU LW LV UDUH WKDW D SRVLWLYH
RXWFRPHLVDFKLHYHGWKURXJKWKLVRSWLRQ
Regulator
,Q 7XUNH\ WKH PRVW HI¿FLHQW FRPSODLQW LV GRXEWOHVV WKDW ¿OHG ZLWK WKH
5HJXODWRU,QRXUFRXQWU\WKH5HJXODWRUKDVFRPHWRWKHFRQFOXVLRQDQG
LV SHUVHYHULQJ ZLWK LWV SRVLWLRQ WKDW LW VKRXOG H[DPLQH WKH FRPSODLQWV
PDGHE\SROLF\KROGHUVLQRUGHUWRDXJPHQWLWVDZDUHQHVVDERXWZKDWLV
JRLQJRQLQWKHSUDFWLFH7KH5HJXODWRULISHUVXDGHGWKDWWKHLQVXUHULVLQ
EUHDFKRILWVFRQWUDFWXDOREOLJDWLRQVGHPDQGVWKHLQVXUHUQRWWRLQVLVWRQ
LWVGHFLVLRQWRUHMHFWWKHFODLP:KHUHWKLVDSSURDFKLVQRWFRPSOLHGZLWK
WKH5HJXODWRULPSRVHVVDQFWLRQV
Courts
,QFDVHWKHSROLF\KROGHURUWKHLQVXUHGGRHVQRWUHFHLYHDQ\RUDGHTXDWHVXP
IURPWKHLQVXUHUXSRQPDWHULDOL]DWLRQRIWKHULVNGHVSLWHUHGUHVVPHFKDQLVPV
DYDLODEOHWKHUHZLOOEHQRRWKHURSWLRQEXWWRUHVRUWWROHJDODFWLRQ
Commercial Courts
,Q 7XUNH\ WKH LQVXUDQFH FRQWUDFW LV UHJXODWHG LQ WKH &RPPHUFLDO &RGH
SURYLGLQJWKDWPDWWHUVDULVLQJRXWRIFRPPHUFLDOSURYLVLRQVPXVWEHGHFLGHG
E\ FRPPHUFLDO FRXUWV UHJDUGOHVV RI ZKHWKHU DOO WKH SDUWLHV LQYROYHG DUH
WUDGHUV 6R FRPPHUFLDO FRXUWV GHDOW ZLWK LQVXUDQFH ODZ GLVSXWHV GXULQJ
GHFDGHVXQWLOWKHHQDFWPHQWRIWKHFRQVXPHUOHJLVODWLRQ&RQVXPHUFRXUWV
HVWDEOLVKHG E\ WKDW VSHFLDO OHJLVODWLRQ EHJDQ WKHUHDIWHU WR H[DPLQH WKH
GLVSXWHVEHWZHHQLQVXUHUVDQGFRQVXPHUV%XWWKLVSUDFWLFHZDVFKDOOHQJHG
E\ VRPH LQVXUHUV DQG WKLV OHG WR DQ LQWHUHVWLQJ GHFLVLRQ RI WKH 7XUNLVK
&RXUWRI&DVVDWLRQZKLFKVWDWHGWKDWWKHUXOHVDERXWWKHFRPSHWHQFHRIWKH
FRPPHUFLDOFRXUWVZLWKUHJDUGWRWKHPDWWHUVUHJXODWHGE\WKH&RPPHUFLDO
&RGHZHUH³OH[VSHFLDOLVÝLVjYLVWKHUXOHVLQWKHFRQVXPHUOHJLVODWLRQ
DQGZRXOGDSSO\WKHUHIRUHH[FOXVLYHO\1:HGRQ¶WWKLQNWKLVUHDVRQLQJWREH
1
WK&LYLO&KDPEHUGHFLVLRQQR(.GDWHG
'U6DPLPhQDQ
ULJKW2QWKHFRQWUDU\WKHSURYLVLRQVRIWKH7XUNLVK&RQVXPHU3URWHFWLRQ
$FWVKRXOGKDYHSULRULW\RYHUWKHFRPPHUFLDOSURYLVLRQVWKHPDLQREMHFWLYH
RI WKH FRQVXPHU OHJLVODWLRQV EHLQJ WR HVWDEOLVK WKH VXSUHPDF\ RI UXOHV
DLPHGDWSURWHFWLQJWKHFRQVXPHU:KHUHRQHRIWKHSDUWLHVLVDFRQVXPHU
WKHQHHGRILWVSURWHFWLRQSUHYDLOVDQGWDNHVWKHSUHFHGHQFH2
Other Courts of First Instance
:KHUH QR FRPPHUFLDO FRXUW H[LVWV LQ PRVW GHSDUWPHQWV FRPPHUFLDO
FRXUWVDUHQRWIRXQGHG\HWRUZKHUHFRPPHUFLDOFRXUWVDUHQRWFRPSHWHQW
WKLVLVIRUH[DPSOHWKHFDVHIRUFHUWDLQLQVXUDQFHFRQWUDFWVUHJXODWHGLQ
VSHFLDO DFWV VXFK DV WKH PRWRU YHKLFOH RSHUDWRU OLDELOLW\ LQVXUDQFH WKH
GLVSXWHVJHQHUDWHGE\LQVXUDQFHUHODWLRQVKLSDUHGHFLGHGE\WKHRUGLQDU\
FRXUWVRI¿UVWLQVWDQFH&RQFHUQLQJWKHGLUHFWDFWLRQRIWKHYLFWLPLQOLDELOLW\
LQVXUDQFHVLWLVQRWFOHDUZKHWKHUFRQVXPHUFRXUWVDUHFRPSHWHQWLIWKH
SROLF\KROGHU LV D FRQVXPHU ,W VHHPV GLI¿FXOW WR ¿QG D OLQN EHWZHHQ WKH
FRQVXPHUSURWHFWLRQDQGWKHGLUHFWDFWLRQ
Consumer Courts
,I D GLVSXWH DULVHV EHWZHHQ D FRQVXPHU DQG D WUDGHU LW ZLOO EH UHIHUUHG
QRUPDOO\WRDFRQVXPHUFRXUW,QVXUDQFHEHLQJD³VHUYLFH´ZLWKLQWKHDPELW
RIWKHFRQVXPHUOHJLVODWLRQSURWHFWLYHQRUPVZLOODSSO\WRVDIHJXDUGWKH
OHJLWLPDWHLQWHUHVWVRIWKHZHDNSDUW\
Arbitration
,QVXUDQFHUHODWLRQVKLSDULVHVQHFHVVDULO\RXWRIDFRQWUDFWFRQFOXGHGZLWK
DWUDGHULQVXUHU7KXVLWLVDSULYDWHODZPDWWHU$UELWUDWLRQLVDGLVSXWH
UHVROXWLRQPHDQVZLGHO\XVHGLQSULYDWHODZDQGDW¿UVWJODQFHWKHUHVHHP
WREHQRREVWDFOHWRUHIHUWRDUELWUDWLRQIRULQVXUDQFHOLWLJDWLRQ+RZHYHUWKH
SUREOHPDULVHVWRNQRZZKHWKHUE\UHIHUULQJWRDUELWUDWLRQWKHPDQGDWRU\
UXOHVDUHFLUFXPYHQWHG7KLVLVWKHFDVHZKHQWKHDUELWUDWRUVDUHJLYHQWKH
DXWKRULW\WRGHFLGH³H[DHTXRHWERQR´DQGQRWLQDFFRUGDQFHZLWKPDWHULDO
ODZSURYLVLRQV
According to Turkish International Arbitration Act
,I WKH LQVXUDQFH FRQWUDFW FRQWDLQV D IRUHLJQ HOHPHQW RU LI WKH SDUWLHV VR
DJUHHWKHDUELWUDWLRQZLOOEHFRQGXFWHGLQDFFRUGDQFHZLWKWKH,QWHUQDWLRQDO
$UELWUDWLRQ$FW7KLVDFWZLOODSSO\HVSHFLDOO\WRGLVSXWHVEHWZHHQ7XUNLVK
LQVXUHUVDQGIRUHLJQUHLQVXUHUV
2
+RZHYHURQHPXVWUHFRJQL]HDOVRWKHUHDOLW\&RPPHUFLDOFRXUWVDUHPXFKPRUHFRQYHQLHQW
IRU LQVXUDQFH ODZ GLVSXWHV WKDW UHTXLUH VSHFLDO NQRZOHGJH DQG H[SHULHQFH LQ UHVSHFW RI
UXOHVDSSOLFDEOHWRLQVXUDQFHFRQWUDFWVEXWWKH\PD\ODFNRIH[SHUWLVHZLWKUHJDUGVWRWKH
SURWHFWLRQDIIRUGHGE\FRQVXPHUODZSURYLVLRQV
114
According to Turkish Civil Proceedings Act
7KH FRPPRQ UXOHV IRU DUELWUDWLRQ DUH LQ WKH &LYLO 3URFHHGLQJV $FW 7KH
SDUWLHV PD\ DJUHH WKDW WKHLU HYHQWXDO GLVSXWHV LQ WKH FRQWH[W RI WKHLU
FRQWUDFWVKDOOEHUHIHUUHGWRDUELWUDWLRQ
,QRXUYLHZLIDQDUELWUDWLRQFODXVHVWLSXODWLQJWKDWDUELWUDWLRQZLOOWDNH
SODFH LQ DFFRUGDQFH ZLWK WKH SURYLVLRQV RI WKH &LYLO 3URFHHGLQJV $FW LV
LQVHUWHG WR WKH LQVXUDQFH FRQWUDFW WKLV ZLOO KDYH WKH HIIHFW RI OLIWLQJ WKH
RSWLRQWRDSSO\WRWKHVSHFLDODUELWUDWLRQVFKHPHIRULQVXUDQFHGH¿QHGLQ
WKH,QVXUDQFH$FWLYLWLHV&RQWURO$FW
According to Insurance Activities (Control) Act Article 30 (= Special
Arbitration Scheme for Insurance)
7XUNLVK ,QVXUDQFH $FWLYLWLHV FRQWURO $FW HQDFWHG LQ SURYLGHV D
VSHFLDO DUELWUDWLRQ VFKHPH IRU LQVXUDQFH GLVSXWHV :H ZLOO H[DPLQH WKLV
VFKHPHLQGHWDLOVEHORZ
1R2PEXGVPDQ±$OWHUQDWLYHWR2PEXGVPDQ
7XUNLVKODZGLGQRWSURYLGHIRU2PEXGVPDQVHUYLFH7KHVSHFLDODUELWUDWLRQ
VFKHPHIRULQVXUDQFHLVVDLGWRKDYHEHHQGHVLJQHGDVDQDOWHUQDWLYHWR
WKH2PEXGVPDQVROXWLRQ
Administration
7KH³6SHFLDO,QVXUDQFH$UELWUDWLRQ6FKHPH´LVPDQDJHGE\DFRPPLVVLRQ
FRQVWLWXWHGZLWKLQWKH8QLRQRI,QVXUHUV5HLQVXUHUV3HQVLRQ&RPSDQLHV
7KH PDMRULW\ RI LWV ¿YH PHPEHUV DUH VHOHFWHG E\ WKH 5HJXODWRU 7KH
FRPSRVLWLRQ RI WKH &RPPLVVLRQ LV DV IROORZV 2QH UHSUHVHQWDWLYH RI
WKH 5HJXODWRU RQH DFDGHPLF WZR UHSUHVHQWDWLYHV RI WKH 8QLRQ DQG RQH
UHSUHVHQWDWLYH RI WKH &RQVXPHU $VVRFLDWLRQ 7KH 5HJXODWRU DSSRLQWV LWV
RZQ UHSUHVHQWDWLYH WKH FRQVXPHU DVVRFLDWLRQ UHSUHVHQWDWLYH DPRQJVW
WKUHHFDQGLGDWHVSURSRVHGE\WKDWDVVRFLDWLRQDQGWKHDFDGHPLF
Claims eligible
7KH6SHFLDO$UELWUDWLRQ6FKHPHIRU,QVXUDQFHLVSURYLGHGRQO\IRUFODLPV
DJDLQVWWKH,QVXUHUDQGWKH³$FFRXQW´
&ODLPVDJDLQVWWKH3HQVLRQ&RPSDQLHVDULVLQJIURPWKHSHQVLRQFRQWUDFW
DUHQRWZLWKLQWKHVFRSHRIDUELWUDWLRQ%XWGLVSXWHVXQGHUOLIHDVVXUDQFH
FRQWUDFWVRU³\HDUO\LQFRPHLQVXUDQFH´FRQWUDFWVFRQFOXGHGZLWKD3HQVLRQ
&RPSDQ\ DXWKRUL]HG WR VHOO OLIH DVVXUDQFH SURGXFWV LI WLWXODU RI D YDOLG
OLFHQFHLQWKHFODVVRILQVXUDQFH³OLIH´ZLOOIDOOXQGHUWKHDUELWUDWLRQVLQFH
FODLPVDULVLQJRXWRILQVXUDQFHFRQWUDFWVDUHVXEMHFWWRDUELWUDWLRQ
3XUVXDQW WR DQ DPHQGPHQW PDGH LQ FODLPV DJDLQVW WKH ³$FFRXQW´
'U6DPLPhQDQ
,QVXUDQFH)XQGDUHDOVRHOLJLEOHIRUDUELWUDWLRQ7KH³$FFRXQW´LVDIXQG
WKDWFRPSHQVDWHVGHDWKSHUVRQDOLQMXULHVORVVDQGGDPDJHV
ZKHUHFRPSXOVRU\LQVXUDQFHVDUHQRWWDNHQRU
WKHLQVXUHGFRXOGQRWEHLGHQWL¿HGRU
LQRWKHUFDVHVPHQWLRQHGE\WKHODZ
&ODLPVDGGUHVVHGE\WKHLQVXUHUEDVHGRQWKHFRQWUDFWRILQVXUDQFHDUHQRW
HOLJLEOHHJIRUUHWXUQRIH[FHVVLYHSD\PHQWVRILQVXUDQFHPRQLHVRUIRU
WKHSUHPLXP
Claimants- Defendant Insurer
&ODLPDQWVZKRPD\DSSO\WRDUELWUDWLRQDUH
SROLF\KROGHUVWKH\DUHSDUW\WRWKHLQVXUDQFHFRQWUDFW
LQVXUHG LQ FDVH RI LQVXUDQFH RQ DFFRXQW RI D SHUVRQ RWKHU WKDQ WKH
SROLF\KROGHUZKHQWKLVSHUVRQLVHQWLWOHGWRVXHWKHLQVXUHU
EHQH¿FLDU\LQSHUVRQDOLQVXUDQFHVLHOLIHDFFLGHQWVLFNQHVV
WKLUGSDUW\YLFWLPLQOLDELOLW\LQVXUDQFHV±7XUNLVKODZJUDQWVWKHYLFWLP
WKHULJKWWRVXHGLUHFWO\WKHOLDELOLW\LQVXUHU
VXEURJHHVRIWKHSHUVRQVDERYHLQFOXGLQJLQVXUHUVLQFDVHWKHLQGHPQLW\
LQVXUHULVVXEURJDWHGWRWKHULJKWVRIWKHLQVXUHGWKHVXEURJDWHGLQVXUHU
PD\DSSO\WRWKHVSHFLDODUELWUDWLRQVFKHPHDJDLQVWWKHOLDELOLW\LQVXUHU
RIWKHSHUVRQOLDEOHIRUWKHLQGHPQL¿HGORVV
&ODLPDQW PD\ EH DQ\ SROLF\KROGHU RU LQVXUHG RU EHQH¿FLDU\ UHJDUGOHVV
RI ZKHWKHU LW LV D FRQVXPHU SURIHVVLRQDO RU WUDGHU 7KH 7XUNLVK VSHFLDO
DUELWUDWLRQVFKHPHLVQRWGHVLJQHGH[FOXVLYHO\IRUFRQVXPHUV
5HVRUW WR DUELWUDWLRQ LV SRVVLEOH RQO\ DJDLQVW WKH LQVXUHU ZKR DGKHUHG
WR WKH DUELWUDWLRQ V\VWHP UHFRXUVH LV SRVVLEOH RQO\ DJDLQVW PHPEHUV RI
WKH³&OXE´$OWKRXJKPHPEHUVKLSLV³YROXQWDU\´QHDUO\³DOO´WKH7XUNLVK
LQVXUHUV DUH PHPEHUV $V RI 0DUFK PDUNHW VKDUHV RI PHPEHU
FRPSDQLHVFRYHULQQRQOLIHDQGLQOLIHEXVLQHVV7KH5HJXODWRU
PDGHLWYHU\FOHDUWKDWLWZRXOGDSSUHFLDWHWKHLQVXUHUVEHFDPH³PHPEHU´
7KLVLQYLWDWLRQZDVYHU\ODUJHO\DFFHSWHGLQVXUDQFHXQGHUWDNLQJVDUH
PHPEHUVRIWKHV\VWHPWKHRYHUDOOQXPEHURILQVXUDQFHXQGHUWDNLQJVLV
7R EHFRPH D PHPEHU WKH LQVXUDQFH FRPSDQ\ PXVW PDNH D ZULWWHQ
GHFODUDWLRQWRWKH&RPPLVVLRQ:KHQQHFHVVDU\IRUPDOLWLHVDUHIXO¿OOHGWKH
LQVXUHUEHFRPHVERXQGE\WKHDUELWUDWLRQDSSOLFDWLRQHYHQLQWKHDEVHQFH
RIDQH[SUHVVDUELWUDWLRQFODXVHLQWKHLQVXUDQFHFRQWUDFW
$JDLQVWDQLQVXUHUZKRLVPHPEHURIWKHVSHFLDODUELWUDWLRQVFKHPHWKH
116
FODLPDQW KDV WR FKRRVH EHWZHHQ VWDWH FRXUWV RU VSHFLDO DUELWUDWLRQ 7KH
FODLPDQW PD\ SUHIHU FRXUWV RU DUELWUDWLRQ LQ LWV VROH GLVFUHWLRQ +RZHYHU
RQFHWKHFKRLFHLVPDGHLWLVQRWSRVVLEOHWRFKDQJHLW
Arbitrators
$UELWUDWRUVKDYHWRZRUNRQO\LQOLIHRUQRQOLIH¿HOGV
7KH\DUHQRWQHFHVVDULO\MXULVWV,QRXUYLHZWKLVLVRQHRIWKHZHDNQHVVHV
RIWKHV\VWHP
5HTXLUHPHQWV IRU EHLQJ DQ DUELWUDWRU DUH H[SHULHQFH FOHDQ UHFRUG RI
FULPHDQGKLJKVWXGLHV7KH5HJXODWRUKDVWKHGXW\WRFKHFNZKHWKHUWKH
FDQGLGDWHVZKRDSSO\IRUEHLQJLQVFULEHGLQ WKHRI¿FLDO OLVW RIDUELWUDWRUV
IXO¿OWKHFRQGLWLRQV$VRI0DUFKWKHUHDUHFDDUELWUDWRUVLQWKH
RI¿FLDOOLVWWKLVLVWKHQXPEHURIWKH¿UVWOD\HUDUELWUDWRUV
7KH &RPPLVVLRQ DSSRLQWV WKH DUELWUDWRUV LQ DFFRUGDQFH ZLWK WXUQ WKHLU
RUGHULQWKHOLVW%XWLIWKH¿UVWDUELWUDWRUZKRVHWXUQKDVFRPHGRHVQRW
KDYHVXI¿FLHQWH[SHUWLVHIRUWKHGLVSXWHLQTXHVWLRQWKHQH[WDSSURSULDWH
DUELWUDWRUZLOOEHDSSRLQWHG
$UELWUDWRUV PXVW EH LPSDUWLDO 7R KHOS DFKLHYLQJ WKLV JRDO D SURKLELWLRQ
LV SURYLGHG 3HUVRQV ZRUNLQJ LQ LQVXUDQFH FRPSDQLHV LQVXUDQFH
LQWHUPHGLDULHVORVVDGMXVWHUVRUWKHLUVSRXVHVRUFKLOGUHQDUHSURKLELWHG
WRDFWDVDUELWUDWRU
$UELWUDWRUV DSSRLQWHG LQ DUELWUDWLRQ SURFHHGLQJV FRQGXFWHG SXUVXDQW
WR &LYLO 3URFHHGLQJV $FW PXVW IXO¿O DOVR WKH UHTXLUHPHQWV RI WKH VSHFLDO
DUELWUDWLRQ VFKHPH,Q RXU RSLQLRQ WKLV LV JRLQJ WRR IDU ,QVXUDQFH LV QRW
PRUHLPSRUWDQWWKDQRWKHUDUHDVZKHUHDUELWUDWLRQLVSRVVLEOH7KHUHLVQR
UHDVRQMXVWLI\LQJDGGLWLRQDOUHTXLUHPHQWVIRULQVXUDQFHDUELWUDWRUVFKRVHQ
E\WKHIUHHZLOORIWKHFRQFHUQHGSDUWLHVZKHQWKHDUELWUDWLRQLVVXEMHFWWR
JHQHUDOUXOHV
Costs
6SHFLDO DUELWUDWLRQ VFKHPH LV QRW ³JUDWLV´ $Q DSSOLFDWLRQ IHH LV FROOHFWHG
IURPWKHDSSOLFDQWFODLPDQW%XWWKRVHIHHVDUHQRWWRRKLJKIRUFODLPV
XSWR7/RQO\7/±FD(852IRUFODLPVEHWZHHQ7/DQG
7/ RQO\ 7/ ±FD (852 IRU FODLPV KLJKHU WKDQ 7/ RQO\7/±FD(8527XUNLVK³/LUDÉHLQJDYHU\XQVWDEOHFXUUHQF\
WKHHTXLYDOHQWVH[SUHVVHGLQ(852DERYHPD\KDYHEHFRPHOHVVHUXQWLO
WKHUHDGLQJ
7KHV\VWHPLVDOLPHQWHGE\LQVXUHUVDQGWKH³$FFRXQW´,QVXUHUVSD\DQ
DQQXDO¿[HGVXEVFULSWLRQIHHDIHHSHU¿OHSDLGEHJLQQLQJIURPWKHth
¿OH RI WKH \HDU )XQGLQJ E\ WKH ³$FFRXQW´ RFFXUV XSRQ UHTXHVW E\ WKH
'U6DPLPhQDQ
5HJXODWRU,QFDVHWKHDQQXDOEXGJHWLVQRWVXI¿FLHQWDGGLWLRQDOVXSSRUW
KDVWREHSURYLGHGE\WKH³8QLRQ´RUWKH³$FFRXQW´ZKDWLVPHDQWE\WKLV
ZRUGZLOOEHH[SODLQHGDIHZOLQHVIXUWKHU
$UELWUDWRUV DUH SDLG GLUHFWO\ E\ WKH &RPPLVVLRQ DV ZHOO DV QRWL¿FDWLRQ
VHUYLFHH[SHQVHV
2WKHUFRVWVDUHERUQHE\WKHORRVLQJSDUW\ZLWQHVVH[SHQVHVH[SHUWLVH
Conditions of application
7KHFODLPDQWPXVW¿UVWKDYHPDGHDUHTXHVWWRWKHLQVXUHU$SSOLFDWLRQWR
VWDUWVSHFLDODUELWUDWLRQLVDOORZHGRQO\LQFDVHRIQHJDWLYHDQVZHURUQR
DQVZHUZLWKLQGD\V
'LVSXWHVUHIHUUHGWRRUGLQDU\RUFRQVXPHUFRXUWVFDQQRWEHEURXJKWODWHU
WRDUELWUDWLRQFKRLFHPDGHRQFHDQGIRUDOO
&RQVHTXHQFHVRIWKHDSSOLFDWLRQ7KHOHJDODFWLRQLVGHHPHGLQLWLDWHGDWWKH
GDWHRIDSSOLFDWLRQSUHVFULSWLRQLQWHUUXSWHGWKDWYHU\GD\7KHDSSOLFDQW
FDQQRWVWDUWOHJDODFWLRQDWVWDWHFRXUWVIURPWKDWPRPHQW
Rapporteur
7KHDSSOLFDWLRQLVH[DPLQHG¿UVWE\D³UDSSRUWHXU´ZKRPXVWKDYHFOHDQ
FULPLQDO UHFRUG EH H[SHULHQFHG LQ LQVXUDQFH DQG KDYH FRPSOHWHG KLJK
VWXGLHV
,IWKHFDVHLVQRWUHVROYHGZKLOHLQWKHKDQGVRIWKHUDSSRUWHXULWZLOOEH
WKHQVXEPLWWHGWRWKHDUELWUDWRUV
7KH UDSSRUWHXU KDV WR FRPSOHWH LWV H[DPLQDWLRQ ZLWKLQ GD\V ,W KDV
WR H[DPLQH ZKHWKHU WKH IRUPDO DSSOLFDWLRQ FRQGLWLRQV DUH IXO¿OOHG WKH
UDSSRUWHXUWDNHVQRGHFLVLRQDVWRWKHPHULWVRIWKHFODLP
7KHUDSSRUWHXUPXVWSUHSDUHDUHSRUWVWDWLQJWKHIDFWXDODQGOHJDOJURXQGV
RIWKHGLVSXWHDQGFRQWDLQLQJLQIRUPDWLRQDERXWWKHDOOHJDWLRQVWRJHWKHU
ZLWKWKHOLVWRIHYLGHQFHVVXEPLWWHGE\WKHSDUWLHVFRQFHUQHG
Procedural Rules
)RUGLVSXWHVRYHU7/DSDQHORIDUELWUDWRUVDWOHDVWWKUHHSHUVRQV
PXVWEHDSSRLQWHG
8QDQLPLW\ LV QRW UHTXLUHG $UELWUDWRUV FDQ WDNH D GHFLVLRQ E\ D VLPSOH
PDMRULW\
7KH DUELWUDO GHFLVLRQ LV UHQGHUHG ³RQ WKH ¿OH´ KHDULQJ LV RSWLRQDO 7KH
FDVH PXVW EH GHFLGHG ZLWKLQ PRQWKV IROORZLQJ DSSRLQWPHQW LI QRW
H[WHQGHGODWHUE\PXWXDODJUHHPHQW2WKHUZLVHWKHFDVHZLOOEHVHQWWR
WKHFRPSHWHQW&RXUW
8SRQGLVPLVVDORIWKHFODLPRQH¿IWKRIWKHPLQLPXPRI¿FLDOODZ\HUIHHV
RQO\ZLOOEHFKDUJHGWRWKHDSSOLFDQW7KLVVROXWLRQLVSURYLGHGLQRUGHUWR
OLJKWHQWKHHFRQRPLFEXUGHQSXWRQWKHFODLPDQW¶VVKRXOGHUEXWLVREYLRXVO\
FRQWUDU\WRODZLQWKDWLWGHFUHDVHVWKHKRO\DQGXQWRXFKDEOHIHHVRIWKH
ODZ\HU
7KHDSSOLFDQWZLOOQRWSD\DQ\IHHIRUWKHDUELWUDWRUVRQO\WKHDSSOLFDWLRQ
IHHLVLQFXPEHQWRQLW
7KH DUELWUDWRUV DUH HPSRZHUHG WR WDNH FHUWDLQ VWHSV 7KH\ PD\ LQ
particular
8SRQGHPDQGRIRQHSDUW\GHFLGHIRUSUHYHQWLYHPHDVXUHV
8SRQGHPDQGRIRQHSDUW\JDWKHURUGHWHUPLQHWKHHYLGHQFHV
$SSRLQWH[SHUWV
&RQGXFWLQYHVWLJDWLRQRQVLWH
7KH DUELWUDO GHFLVLRQV FRQFHUQLQJ GLVSXWHV XS WR 7/ DUH ¿QDO 7KH
SDUWLHVFRQFHUQHGFDQQRWDSSHDODJDLQVWWKHP,IWKHFODLPLVRYHU7/
DSSHDOWRWKHXSSHUOD\HUZLWKLQWKHVSHFLDODUELWUDWLRQVFKHPHLVSRVVLEOH
8SRQ DSSHDO WKH HQIRUFHPHQW LV VXVSHQGHG 7KHUH DUH VSHFLDO SDQHOV RI
DUELWUDWRUV FUHDWHG VROHO\ IRU DSSHDO SXUSRVHV 7KH DSSHDO SURFHHGLQJV
PXVWQRWODVWPRUHWKDQWZRPRQWKV7KHGHFLVLRQUHQGHUHGXSRQDSSHDO
LV ¿QDO +RZHYHU IRU GLVSXWHV RYHU 7/ LW LV DOORZHG WR VHL]H WKH
6XSUHPH&RXUWIRUDIXUWKHUREMHFWLRQ
)RUREMHFWLRQDQGDSSHDOSXUSRVHVZKDWLVUHOHYDQWLVWKHDPRXQWRIWKH
GLVSXWH DQG QRW WKH DPRXQW DOORZHG E\ WKH DUELWUDWRUV ,I LQ UHVSHFW RI
D FODLP IRU 7/ WKH DUELWUDWRUV FRQGHPQHG WKH LQVXUHU WR SD\ 7/
ERWKSDUWLHVZRXOGEHHQWLWOHGWRDSSHDO
2EMHFWLRQ WR WKH 6XSUHPH &RXUW IRU SURFHGXUDO JURXQGV LV SRVVLEOH
UHJDUGOHVV RI WKH DPRXQW HJ GHFLVLRQ UHQGHUHG DIWHU WKH DUELWUDWLRQ
SHULRGLVH[KDXVWHGGHFLVLRQRQVRPHWKLQJZKLFKZDVQRWFODLPHGGHFLVLRQ
RXWVLGHWKHFRPSHWHQFHRIWKHDUELWUDWRUVQRGHFLVLRQIRUWKHFODLPVDQG
GHIHQFHV
$UHWKHDUELWUDWRUVDOORZHGWRGHFLGH³H[DHTXRHWERQR´³DFFRUGLQJWRWKH
ULJKWDQGJRRG´RU³IURPHTXLW\DQGFRQVFLHQFH´":HEHOLHYHWKLVLVQRW
SRVVLEOHIRUWZRUHDVRQV
7KH&LYLO3URFHHGLQJV$FWDSSOLFDEOHDVFRPSOHPHQWDU\FOHDUO\VWDWHV
WKDWWKHDUELWUDWRUVDUHQRWHPSRZHUHGWRGHFLGH³H[DHTXRHWERQR´LI
QRWH[SUHVVO\DXWKRUL]HGE\WKHFRQFHUQHGSDUWLHVWRGRVR
7KHGHFLVLRQVDERXWFODLPVKLJKHUWKDQ7/DUHVXEMHFWWRDSSHDO
%XWDSSHDOLVUHOHYDQWRQO\IRUOHJDOHUURUV$SSHDODJDLQVWDGHFLVLRQ
'U6DPLPhQDQ
EDVHGRQWKHHTXLW\GRHVQRWVHHPORJLF7KHUHIRUHWKHDUELWUDWRUVPXVW
EDVH WKHLU GHFLVLRQ RQ PDWHULDO ODZ SURYLVLRQV $V LW LV QRW MXVWL¿DEOH
WR KDYH GLIIHUHQW UHJLPHV IRU VPDOO FODLPV DQG WKH ELJ RQHV WKH
UHTXLUHPHQWWRDSSO\PDWHULDOODZSURYLVLRQVH[LVWVDOVRIRUFODLPVOHVV
WKDQ7/
7KH DUELWUDO GHFLVLRQV DUH HQIRUFHDEOH LPPHGLDWHO\ 7KH SULQFLSOH LV WKDW
DSSHDO GRHV QRW VWRS HQIRUFHPHQW %XW HQIRUFHPHQW PD\ EH SRVWSRQHG
E\DMXGLFLDOGHFLVLRQLIDGHTXDWHVHFXULW\LVIXUQLVKHG7KHVROXWLRQLVWKH
VDPHIRUFRXUWGHFLVLRQV
Pros and Cons
Advantages of the special arbitration scheme
7KHVSHFLDOLQVXUDQFHDUELWUDWLRQVFKHPHLVDGYDQWDJHRXVIRUSROLF\KROGHUV
LQVXUHGEHQH¿FLDULHVHVSHFLDOO\LQWZRUHVSHFWV
&RVWV DUH FRQVLGHUDEO\ OHVV EXW ZH PXVW XQGHUOLQH WKDW WKLV IDFW
HQFRXUDJHV DQG LQFUHDVHV WKH ³KRSHOHVV´ DSSOLFDWLRQV ± ³OHW¶V WU\ ZH
ORVHQRWKLQJ´WHPSWDWLRQ
+LJKVSHHGLVDFKLHYHGWKLVLVSDUWLFXODUO\LPSRUWDQWLQDFRXQWU\ZKHUH
WKHDYHUDJHGXUDWLRQRIFRXUWFDVHVLVUHODWLYHO\ORQJ±WZR\HDUV
7KH ³KLJK VSHHG´ LV DOVR RI XWPRVW LPSRUWDQFH IRU LQVXUHUV )RU FODLPV
PDGHDJDLQVWWKHPLQVXUHUVKDYHWRFRQVWLWXWHLPSRUWDQW³UHVHUYHV´WKDW
PD\DGYHUVHO\DIIHFWWKHLU¿QDQFLDOVKHHWV
7KHDUELWUDODZDUGVZHUHVRIDUPRUHGHWDLOHGWKDQWKHFRXUWGHFLVLRQV$V
FRXUWVDUHVXEPHUJHGLQDYHU\ODUJHQXPEHURIGLVSXWHVRIWHQGHFLVLRQV
DUHZULWWHQDVVKRUWO\DVSRVVLEOH
2QHRIWKHSULQFLSOHVRIWKHSULYDWHDUELWUDWLRQLV³SULYDF\´$UELWUDODZDUGV
PD\ QRW EH SXEOLVKHG ZLWKRXW WKH H[SUHVV FRQVHQW RI WKH SDUWLHV WR WKH
GLVSXWH+RZHYHUGHFLVLRQVUHQGHUHGRIWKHVSHFLDODUELWUDWLRQVFKHPHIRU
LQVXUDQFHDUHUHJXODUO\SXEOLVKHGZLWKRXWJLYLQJWKHQDPHVLQWKHKRSH
WKDWLQVXUHUVZRXOGGUDZWKHQHFHVVDU\OHVVRQV
Disadvantages
7KHVSHFLDODUELWUDWLRQVFKHPHVKRXOGDOVRH[WHQGWRGLVSXWHVJHQHUDWHG
E\SHQVLRQFRQWUDFWV
7KHVSHFLDODUELWUDWLRQVFKHPHVKRXOGFRPSULVHRQO\³VPDOOFODLPV´,QRXU
RSLQLRQWKHVXEPLVVLRQRIODUJHFODLPVWRDUELWUDWLRQLVQRWDJRRGVROXWLRQ
VLQFH WKRVH FODLPV UHTXLUH PRUH WLPH DQG VSHFLDO SURFHGXUHV IRU EHLQJ
DGHTXDWHO\GHFLGHG7KHUHDUHFODLPVEURXJKWWRDUELWUDWLRQIRUPRUHWKDQ
WKUHHPLOOLRQ86,QWKHZRUVWVFHQDULRVXFKELJFODLPVZRXOGEHGHFLGHG
E\DSDQHOZLWKDPDMRULW\RIQRQMXULVWVDIWHUDQH[DPLQDWLRQRQWKH¿OH
120
DQGZLWKLQWZRPRQWKV,QWKDWFRQWH[WWKHGHIHQGDQWLQVXUHUVZRXOGKDYH
EHHQJLYHQRQO\RQHRSSRUWXQLW\IRUWKHLUZULWWHQVXEPLVVLRQV
,Q WKH OLVW RI DUELWUDWRUV WKHUH DUH DV PXFK QRQMXULVWV DV MXULVWV ,Q P\
EHOLHIDQRQMXULVWDUELWUDWRUVKRXOGQRWEHDSSRLQWHGDV³VROHDUELWUDWRU´
VLQFH GHFLVLRQV H[ DHTXR HW ERQR DUH QRW DOORZHG :KHWKHU LW LV DQ
DSSURSULDWH VROXWLRQ WR DSSRLQW QRQMXULVW DUELWUDWRUV LQ WKH SDQHO VHHPV
DOVRGHEDWDEOH
2QWKHRWKHUKDQGWKHOHYHORIWKHDUELWUDWRUVVHHPVDOVRWREHDFRQWURYHUVLDO
LVVXH7KHTXDOLW\RIWKHGHFLVLRQVUHQGHUHGLQWKHVSHFLDODUELWUDWLRQLVQRW
EHORZWKHFRXUWGHFLVLRQV+RZHYHUWKLV³QRWEDGÓHYHOLVQRWVXI¿FLHQW,W
VKRXOGEHLPSURYHG7KLVUHTXLUHVDUELWUDWRUVRIKLJKHUIRUPDWLRQ
Reliability
,VWKHQHZVSHFLDODUELWUDWLRQVFKHPHUHOLDEOH"7KLVLVYLWDOIRULWVIXWXUH
DQG LQWHQGHG SXUSRVH $OWKRXJK WKH QXPEHU RI DSSOLFDWLRQV LQFUHDVHV
HDFK\HDUZHGRQ¶WEHOLHYHWKDWWKLVGHPRQVWUDWHVDZLGHVSUHDG³WDNHXS´
E\WKHWDUJHWHGFRQVXPHUV0RUHWKDQKDOIRIWKHDSSOLFDWLRQVDUH¿QDOO\
UHMHFWHG 7KLV IDFW VKRZV WKDW WKH SURSHU YLFWLPV GRQ¶W FKRRVH \HW WKH
VSHFLDODUELWUDWLRQDQGSUHIHUFRXUWV
6RPH¿JXUHV
6WDUW$XJXVW
7KHQXPEHURIDSSOLFDWLRQVLQFUHDVHHDFK\HDU
$VRIHQG6HSWHPEHUDSSOLFDWLRQV
QRQOLIHOLIH
$WRWDORIFDVHVZHUHGHFLGHGE\DUELWUDWRUV
$YHUDJHGXUDWLRQGD\V
RIFODLPVEHORZ7/
Conclusion
7KHVSHFLDOLQVXUDQFHDUELWUDWLRQVFKHPHKDVEHHQUHYHDOHGVRIDUDVXVHIXO
,WPXVWEHPDLQWDLQHGEXWDWWKHVDPHWLPHLPPHGLDWHO\LPSURYHG

Alternative Dispute Resolution Systems Regarding Private

Transkript

Benzer belgeler

Hakemli Makale - Eğitim Bilim Toplum

Sosyal güvenlik ihtiyacı insanlık tarihi kadar eskidir. Sözkonusu

SAYI 4

the Adobe Acrobat version of CPR Working Paper 16

AYDIN ingilizce kapak.indd

General view of Yahşibey houses. Esin Senan house.