COMPLAINTS AND OUTCOMES

entered into in good faith and there was no obligation on an insurer to verify the information at the sales stage.

She said the insurer had created a clear duty of disclosure and Mr Y should, in the position of a reasonable person, have known that he needed to disclose all losses suffered in the last five years.

The ombudsman upheld the insurer’s decision to reject the claim.

ONE CLAIM OR TWO?

Mr P filed a complaint after Infiniti Insurance Company, with which he had a car maintenance warranty, settled only a portion of a claim for damage to the engine of his BMW X5.

The issue facing the Ombudsman was whether two separate claims with the same components under a limitedliability provision in a policy should be treated as two claims or as one, with a single application of the limit.

The policy schedule stated that the insurer’s liability for the repair or replacement of any vehicle part was limited to a specified amount. In this case, the component was the engine, on which the limit was R70 000.

Ten months after buying the BMW, the engine failed as a result of a specialised unit on the camshaft, the Vanos unit, being faulty. The quotation for repairs was about R60 000 and the insurer paid R41 345 in terms of the policy’s limit of liability for an engine.

About two months later, the oil pump failed. This led to a bearing failure which resulted in the engine seizing. The quoted cost for these repairs was about R135 000.

According to the assessor appointed by the insurer, the repairing dealer was asked to strip the oil pump for inspection. It was observed that the oil pump gears were worn, limiting the pump’s ability to function. The lack of oil pressure resulted in bearing failure.

In its responses to the complaint, Infiniti advised that, based on the assessor’s findings and having considered the vehicle’s engine repair history, the oil pump failure was already imminent at the point of the previous engine repair and the damage to the pump and bearings would not have occurred in the 880km the vehicle had covered since the first failure.

It was Infiniti’s opinion that the first engine failure was a contributing factor to the second. For this reason, the insurer was prepared to pay out only the balance of the engine benefit limit. It was prepared only to pay the balance of R28 655, both amounts totalling the maximum engine limit of R70 000.

Mr P wanted the insurer to pay R70 000 towards the costs of the second repair and of the opinion the second failure was unrelated to the previous failure. He stated if the second failure was related, then the dealer should have picked this up at the time and its failure to do so amounted to negligence.

The insurer maintained its stance that the current failure was related to the previous claim and was not liable to pay another R70 000.

The ombudsman pointed out that nowhere in the report did the assessor state that the existing damage was related to the previous problems with the car. To support this, Mr P obtained a report from the dealer stating that the repair had no relation to the previous repair carried out on the vehicle when the Vanos unit was replaced.

The ombudsman was of the view that the insurer had not provedthat the two incidents were related. She also stated that the insurer could not rely on the final decision of its claims department, as its technical expertise could not be viewed as independent.

Infiniti was requested to settle the claim in terms of the limit of liability for the engine component, being R70 000, which it agreed to do.