My insurance claim was rejected. What can I do?

If your insurer has rejected your claim, do three things in order. Get the rejection and the reasons for it in writing. Use the insurer's own internal dispute process within the deadline stated in that letter. If you are still unhappy, take it to the National Financial Ombud Scheme, which costs you nothing.

The deadlines matter more than the argument. Short-term insurance policies almost always contain a time bar. You typically have around 90 days from the rejection letter to dispute it, and a further limited period, often six months, to issue summons. Those periods are much shorter than the three year period for an ordinary contractual claim under the Prescription Act 68 of 1969, and the courts will enforce them. Read your rejection letter for the exact dates. The insurer is required to spell them out.

Get the rejection in writing

A call centre agent saying "it has been repudiated" is not a rejection you can work with. Ask for a written decision that states the specific reason and the specific policy wording relied on. Ask for a copy of your full policy schedule and the wording that applied on the date of the loss, not the current version.

Then read it against what actually happened. Insurers reject in categories, and knowing which category you are in tells you what evidence you need.

The usual reasons, and what beats them

Non-disclosure or misrepresentation. You did not tell the insurer something relevant when you took out the policy or renewed it, such as a previous claim, a modification to the car, or who really drives it. This is the most common ground. The question is whether the undisclosed fact was material, meaning whether a reasonable person would have considered it relevant to the insurer's assessment of the risk. Insurers over-reach here, especially where the fact had nothing to do with the loss.

Breach of a policy condition. No tracking device fitted, security gates not activated, the vehicle driven by an unlicensed driver, or the driver over the alcohol limit. Check whether the condition was actually in the policy, whether it was properly brought to your attention, and whether the breach had anything to do with the loss.

An exclusion. Wear and tear, gradual deterioration, lack of maintenance, and damage from a cause the policy simply does not cover. This is usually an evidence fight, and an independent assessor's report can change the answer.

Premium not paid. If a debit order bounced and the policy had lapsed, the claim usually fails. Check the actual bank record. Insurers sometimes get this wrong.

Under-insurance or average. Not a rejection, but a partial payment. If you insured a home for R900 000 when it should have been R1 500 000, the insurer may reduce the payout in proportion.

Evidence to gather before you argue

Put the file together before you write a word of argument. You will need:

• the rejection letter and any earlier claim correspondence
• your policy schedule and the full policy wording that applied on the date of loss
• the original proposal form or the recording of the telephone sale, if you can get it, because that is where a non-disclosure allegation is tested
• the police case number for theft, hijacking or accident claims
• photographs of the damage, taken before repairs
• an independent assessor's report or a second repair quote where the dispute is about cause or amount
• bank statements showing the premium was paid, where lapse is alleged
• the tracking company's installation and monitoring certificate, where a tracking condition is alleged
• receipts, invoices and proof of ownership for stolen or damaged items

Attach copies, never originals, and keep a list of what you sent and when.

Step one: the insurer's internal dispute process

Every insurer must have one and must tell you about it. Write to the dispute or complaints department, not to the call centre. Keep it short and factual:

• your policy and claim number
• the date of the loss and the date of the rejection letter
• the reason the insurer gave, quoted from the letter
• why it is wrong, with documents attached
• what you want, stated plainly

Attach evidence rather than describing it. An assessor's report, a repair invoice, a bank statement showing the premium went off, photographs. Send it by email so you have a record and a date, and keep everything.

A worked example

Sipho's car is stolen from outside a friend's house. The insurer rejects the claim because the tracking device the policy required was not active. Sipho's file shows the tracker was installed and that he had paid the monitoring fee every month, but the tracking company had deactivated the unit after a billing error on its side.

The figures here are illustrative only. Sipho's car was insured for R180 000. His internal dispute letter quotes the policy condition, attaches the installation certificate, the monitoring company's debit order history and an email from the company admitting its own error, and asks the insurer to reconsider. The insurer confirms the rejection. Sipho then lodges with the National Financial Ombud Scheme, which asks whether the breach of the tracking condition was Sipho's fault at all and whether it had any bearing on the theft. The complaint is a good candidate for the ombud precisely because it turns on fairness rather than on a technical reading of the wording.

Whether Sipho recovers the full sum, a reduced amount or nothing depends on the facts and the ombud's view. The point of the example is the method: written reasons, the right evidence, the internal step, then the free escalation, all inside the deadlines.

Step two: the National Financial Ombud Scheme

If the insurer confirms its rejection, or ignores you, escalate. The National Financial Ombud Scheme of South Africa now handles complaints that used to go to the Ombudsman for Short-Term Insurance, as well as long-term insurance, banking and credit complaints. It is free for consumers, you do not need an attorney, and its decisions bind the insurer in the way its rules provide. See How to complain to the Ombudsman for Short-Term Insurance for the step by step process and what to send.

Two limits are worth knowing. You normally have to complete the insurer's internal process first. And the scheme deals with the fairness and the merits of the claim decision, not with the advice you were given when the policy was sold. Complaints about poor advice from a broker or financial adviser go to the FAIS Ombud instead.

Realistic timeline

• Rejection letter to internal dispute: send your dispute within days, not weeks. The 90 day window is a maximum, not a target.
• Insurer's internal review: insurers usually respond within a few weeks, though complex claims take longer. Ask for a final written decision.
• Ombud complaint: the scheme acknowledges the complaint, checks it is within its mandate, puts it to the insurer, and then exchanges submissions. A simple motor dispute can take a few months. A large fire or business claim with assessor reports on both sides takes longer.
• Court: if it comes to that, expect a year or more, and expect the policy time bar to have been the deciding factor in whether you could go at all.

Your rights and the insurer's rights

You have the right to: written reasons for a rejection; a copy of the policy wording relied on; access to the insurer's internal dispute process; a free complaint to the National Financial Ombud Scheme; and to have a partial payment explained line by line.

The insurer has the right to: investigate the claim before paying; ask for documents and an assessor's inspection; rely on a valid exclusion or condition that was properly disclosed; reduce a payout for under-insurance; and reject a claim that is fraudulent or deliberately exaggerated.

Step three: court, and only if it is worth it

Litigation against an insurer is expensive and slow, and the policy time bar may already have closed the door. Before you go there, check the six month clock in your rejection letter. If it is running, an attorney can issue summons to stop it while the dispute continues.

Whether it is worth suing depends on the size of the claim against the likely costs. For a claim of a few thousand rand, the ombud route is almost always the better answer. For a total house fire or a large business interruption claim, take advice early. Contingency arrangements under the Contingency Fees Act 66 of 1997 are possible in some insurance disputes, but they are far less common than in injury claims, so ask.

If you cannot afford an attorney

The internal dispute and the ombud complaint cost nothing and need no attorney. If the sale of the policy is the real problem, the FAIS Ombud is also free. Legal Aid South Africa can be reached on 0800 110 110 and applies a means test. For a consumer dispute that is not really an insurance claim, such as a warranty sold with an appliance, the National Consumer Commission and the Consumer Goods and Services Ombud are the free routes.

Common mistakes and what they cost

• Arguing on the phone. Nothing said on a call helps you later. Every point should be in writing.
• Letting the 90 days pass while waiting for a call back. The insurer can then refuse to reopen the file.
• Ignoring the six month summons clock. This is the mistake that ends otherwise good claims.
• Repairing before the assessor has inspected. You lose the evidence of what caused the damage.
• Rounding up the claim. An exaggerated claim can void the whole policy, not just the padded part.

What not to do

Do not accept a settlement in full and final settlement while you are still gathering evidence. Do not sign a discharge form without reading it. Do not "adjust" the facts of the loss to fit the policy, because a fraudulent or exaggerated claim usually voids the whole policy, not just the disputed part. And do not let the deadline in the rejection letter pass while you wait for someone to call you back.