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.).
Principles of action.
The management that PROMEDE intends in this field is based on three fundamental principles:
- Personalized treatment of claims through technical and objective analysis by independent specialized professionals (doctors and lawyers).
- The speed in the resolution of claims that is established in 20 days for administrative and 30 days for medical claims.
- The promotion of Mediation, as a means to resolve claims through:
- The actual analysis of the facts and motives.
- The exact assessment of the consequences.
- The creation of a space for dialogue with the affected party, the client and the insurer, by an independent and disinterested entity in the final result. For these purposes, Promede is registered as a Mediation Institution in the Registry of Mediators of the Ministry of Justice.
Article 5 of the Order establishes in its point 1:
“The heads of the customer service department or service and the customer ombudsman must be persons with commercial and professional reputation, and with adequate knowledge and experience to carry out their functions.
There is commercial and professional honor in those who have been observing a personal trajectory of respect for mercantile or other laws that regulate economic activity and business life, as well as good commercial and financial practices.
Those who have performed functions related to the financial activity of the entity or entities in question possess the knowledge and experience appropriate for the purposes provided for in this Order. ”
Promede has been, for 10 years, an entity designated as the defender of the insured of various insurance companies, offering them a comprehensive service in matters related to the resolution of their clients’ claims, regarding their rights and interests.