Both Law 44/2002, of November 22, which enhances the protection of customers, and Order ECO / 734/2004, of March 11, on the departments and services of customer service and the client ombudsman of entities financial, establish the obligation for insurance companies to create a service of attention to the insured itself and voluntarily, for reasons of image, independence and objectivity vis-à-vis the insured, advises and regulates the establishment of the figure of the external Insured Ombudsman to the company.
By the Insured Defender, for an insurance company dedicated to the health branch, it is understood that it is the body that is in charge of receiving, studying and responding to complaints, suggestions and claims submitted by clients on certain aspects of content, application and the effects of the insurance contract they have signed.
By virtue of the nature of the claims, two types can be understood:
Claims of an administrative nature are those related to:
- The interpretation of the particular and / or general conditions of the insurance contract.
- The application of exclusions from the coverage of the contracted policy.
Claims of a medical nature are related to:
- The effects of the services provided (medical complications, assessment of the consequences caused, calculation of the amounts of compensation, etc.).