Insurance claim rejection appeal letter

An insurance rejection letter is written to sound final. It is not. The Policyholder Protection Rules give you at least 90 days from the date of the rejection notice to make representations to the insurer, and this template is the document that uses that period. Insurers do change their minds, but they change them when someone puts the right facts in front of them in writing.

What this document does and when to use it

This letter does two separate jobs and you should not drop either. The first is to make representations against the rejection: to ask the insurer to reconsider and to say exactly why the decision is wrong. The second is to demand full written reasons, meaning every policy clause the insurer relies on, quoted, together with copies of every report, assessment or statement it used to reach the decision.

The second job matters even when the first fails. If the insurer holds its position, your next stop is the National Financial Ombud Scheme South Africa, and you want to arrive there holding the insurer's own written reasons rather than a one-line letter saying the claim was repudiated in terms of the policy.

Use it after a written rejection of any short-term or long-term claim: motor, household contents, buildings, cellphone, funeral, disability or retrenchment cover. Use it too where the insurer paid part and refused the rest, because a partial rejection is a rejection of the part refused. Do not use it where nothing has been decided. If your claim is simply sitting there, chase the claim instead.

Before you send it: get these facts straight

Do not write a word until you can put four things on the table.

The exact ground of rejection. Read the letter line by line and name the ground: an exclusion, late notification, non-disclosure when the policy was taken out, an unpaid premium, a wear and tear clause, or breach of a condition such as an alarm requirement. Your letter must answer that ground. If the letter names no clause at all, that itself becomes something you raise.

The policy wording, not just the schedule. The schedule shows your name and the sums insured. The wording is the booklet with the exclusions in it. You need both, and you need to quote the clause accurately.

A dated timeline of your own. When it happened, when you reported it, who you spoke to, when the assessor came, when the rejection arrived. Dates beat adjectives.

What you claimed, in rands, with proof for each figure. A claim for R38 400 needs quotes or invoices that add up to R38 400.

Then gather the attachments: photographs, the police case number, the claim form, quotes, any assessor's report, service records, proof that the premium went off, and any note of what the broker told you.

Walking through it, paragraph by paragraph

The heading block. REPRESENTATIONS AGAINST THE REJECTION OF A CLAIM, then the policy number, the claim number and your identity number. The word representations is deliberate. It is the word the Policyholder Protection Rules use, and it signals that this is a formal step and not a complaint call.

Paragraph 1 closes off the cheapest reason to reject you again. It says you are the policyholder, when the policy started, and that "Premiums have been paid up to and including [DATE OF LAST PREMIUM PAID]".

Paragraph 2 is the incident. The template asks for it "in two or three plain sentences, including the place". This paragraph is not where you argue. It is where you fix the facts, the reporting date, the amount claimed and the police case number.

Paragraph 3 is the one people rush and should not. It records the rejection by date and asks you to "quote or summarise the reason exactly as the insurer put it". If the insurer said the damage was caused by gradual deterioration, write gradual deterioration. Answering a softened version of the ground is the commonest way these letters fail.

Paragraph 4 is one line asking for reconsideration. Leave it as it is.

Paragraph 5 carries the argument, in numbered sub-paragraphs. Keep only the ones that are true for you and delete the rest. 5.1 says the clause does not cover this situation and makes you explain why. 5.2 says the insurer's facts are wrong and makes you say what actually happened and point to the document that shows it. 5.3 deals with non-disclosure, and is built around what you did disclose, to whom, and on what date. 5.4 deals with late notification, and note the fall-back it offers: if you were late, say why the delay did not prejudice the insurer. 5.5 deals with premiums and with a debit order the insurer failed to present. 5.6 deals with wear and tear, where an independent report from a plumber, electrician or engineer usually decides the outcome.

One good sub-paragraph with a document behind it beats four assertions.

Paragraph 6 lists the attachments. Number them and match the numbers to the list at the foot of the letter.

Paragraph 7 is your request, in three parts: full written reasons with every clause quoted and every report handed over, reconsideration in light of what you have said, and a written decision within a stated number of days. Put a real number in.

Paragraph 8 records that you are inside the representation period. Paragraph 9 asks the insurer to confirm that its internal complaints process is exhausted and to give you the complaints department details. That paragraph builds your bridge to the ombud, so do not delete it.

A worked example

This example is illustrative only.

Nomsa Dlamini's geyser bursts overnight in a flat in Bellville. Water ruins a bed, a wardrobe and a laptop, and she claims R38 400 for the contents. Six weeks later the insurer rejects the claim, saying the loss was caused by gradual deterioration of the geyser, which the policy excludes.

Her paragraph 2 says the geyser burst on 3 May, that she reported it on 4 May, and that she claimed R38 400. Her paragraph 3 quotes the rejection word for word, including the clause the insurer named. She deletes 5.2 to 5.5 and keeps 5.1 and 5.6. Under 5.6 she writes that the geyser was serviced in November by a named plumber, and that an attached report from a second plumber finds the cause was a failed thermostat and a jammed safety valve rather than corrosion. Her paragraph 6 lists five attachments: the rejection letter, the policy schedule, the service invoice, the plumber's report and photographs of the ceiling.

Her letter runs to under two pages. The plumber's report is what does the work.

The mistakes that make one of these useless

Answering a ground the insurer did not raise. You write three pages about the alarm and the insurer rejected you for late notification. The reply ignores everything you said, and you have burned weeks of your 90 days.

Arguing fairness instead of wording. "This is unfair after eleven years of premiums" is a sentence the ombud might one day care about. The claims department cannot act on it. Give them the clause and the facts.

Sending it with nothing attached. A letter that describes a plumber's report but does not include it is an unsupported assertion. Attach it or do not mention it.

Accusing someone of dishonesty. Say the facts are wrong, not that the assessor lied. An accusation turns a claims query into a dispute and hardens the file.

Leaving the deadline vague. "As soon as possible" gives you nothing to escalate on. A stated date gives you the moment at which you can say the insurer failed to respond.

Missing the representation period. The 90 days is the friendliest deadline in this process. Once it goes, your route narrows to the ombud and to court, both slower.

How to submit it and prove you did

Send it to both the claims address and the complaints address on the rejection letter. Keep the sent item, and use a delivery or read receipt if your mail client offers one. Post a copy by registered post and keep the slip, or hand it in at a branch and have your copy signed and dated.

Send it as one PDF bundle, letter first and attachments behind it in the order you listed them, named something like Dlamini claim 1234567 representations. One clean file gets read. Nine loose photographs do not.

Then diarise two dates: the day the insurer must reply by, and the last day of your representation period. Follow up in writing when the first passes.

If it does not work

Escalate internally first, to the complaints department, and ask for a final written decision. The ombud will usually want to see that you did.

Then refer the matter to the National Financial Ombud Scheme South Africa. It is free to consumers and you do not need an attorney. Our guide on how to complain to the Ombudsman for Short-Term Insurance sets out what to send, and my insurance claim was rejected, what can I do covers the route end to end.

Watch the clock separately from the ombud process, because a claim on a policy can prescribe. Read how long do I have to claim from an insurance company before any date passes. Legal Aid South Africa is on 0800 110 110 and university law clinics assist at no charge.

LawMatch is not a law firm and this article is general information, not legal advice about your situation.

Frequently asked questions

Does this letter stop time running?

No. Making representations is a step in the insurer's own process. It does not interrupt prescription under the Prescription Act 68 of 1969 and it does not extend a limitation period written into your policy. Watch both clocks.

Do I need an attorney to write it?

No. The template is built to be completed by the policyholder. Pay for an attorney's hour when the amount is large, when the insurer alleges you were dishonest, or when the dispute turns on the meaning of a clause rather than on the facts.

The insurer will not give me the assessor's report. What now?

Ask again in writing, quoting paragraph 7.1, and record the refusal. Say in your ombud submission that you asked and were refused. The ombud can call for the insurer's file.

They paid part of the claim. Can I still use this?

Yes. Treat the refused part as a rejection and make representations about that part only. Say which amount you accept as paid and which remains in dispute, so nobody can suggest you accepted the lot.

What if the rejection letter gives me less than 90 days?

The Rules require the insurer to allow you at least 90 days from the rejection notice. If the letter gives less, say so in your representations and give the date you calculate. Then work to the earlier date anyway, so nothing turns on the argument.