Repudiation (noun): ‘When an Insurer rejects a claim or refuses to honour the contract / policy’
Repudiation (noun): ‘When an Insurer rejects a claim or refuses to honour the contract / policy’
You have the right to inform yourself.
Most insurance policies require the insured to report/submit an insurance claim within a certain number of days. Failure to adhere to these requirements may result in a rejection of a valid claim. It is crucial to understand and adhere to the requirements of the policy.
If an insurance claim is rejected by an insurer or if the claim amount awarded is lower than the expense being sought to be covered under the policy, the aggrieved insured person may first file a complaint directly to the insurance company concerned.
If you still do not find success in this process, you may then approach Repudiation SA to assist you in recovering your insurance payout.
While the reasons for insurers rejecting claims vary from insurance policy to insurance policy and the types of cover, there are basic insurance terms and conditions that apply across the board:
Your failure to meet the aforementioned terms and conditions will no doubt lead to your claims being rejected.
When submitting a claim, the claims consultant will guide you on what information and documentation is needed to process the claim, depending on the event which led to the claim. However, the typical requirements include:
If you have provided inaccurate information to your insurer or you have failed to disclose material information and facts at the inception of your policy, it may result in an unsuccessful claim later on. An insurer uses the information provided by the insured to determine the risk profile and the subsequent rate based on the profile as well as additional premiums, exclusions, or warranties of the policy. If the insurer discovers that inaccurate or incomplete information was provided about you, or anyone insured on your plan or that you have failed to disclose material information and facts they may reduce your claim or decline your claim entirely.
If you want your insurance to pay for something, you must have had coverage when the event happened. If you missed a payment, you might have a bit of time to catch up before losing coverage. Make sure you know when your coverage ends for each benefit.
If you claim for something from your insurance that is indicated to be excluded in your policy documents, your claim will be declined, as an exclusion means that you do not have cover for that condition or event. An example is a medical exclusion on death, disability or dreaded disease benefits that were placed on your policy.
When taking out an insurance, it is important for the insurance company to establish that you have an insurable interest in the property. In other words, you would have to provide sufficient evidence to show that you would stand to suffer a direct financial loss if there is a claim. An insurance company may not cover the property if you are not directly responsible for it. For example, if your house is damaged by a fire, the value of your house will be reduced, and whether you pay to rebuild the house or sell it at a reduced price, you will suffer a financial loss resulting from the fire. The insured bears the responsibility of proving that an insurable interest exists.
Over-insurance occurs when you are insured for more than the actual value of the insured item. It essentially means that your cover amount is greater than your actual need. This results in an unnecessary high premium being paid for the additional cover that you will not enjoy. Over insurance amounts to enrichment. Insurers are obligated to only place you in the same position prior to your loss.
Under-insurance occurs when the insured value is less than the actual value of the insured’s property. When under-insurance takes place, the insurance payout could be subject to the principle of “average”. “Average” is applied because the premium that has been paid is for a lesser amount of cover and as such, a lesser amount is paid out for the claim.
In the insurance industry, “average” is a calculation used to determine if a property or asset is under-insured, and by how much. If the insurance coverage is less than the actual value, then the claims pay-out for a loss will be reduced in proportion to the lower coverage amount. The settlement amount is determined by applying the below formula:
Loss x Sum insured
____________________ = Settlement based on “average”
Actual value
Short term insurance provides cover for vehicles, property, home contents, medical insurance, GAP cover, travel insurance, business, or personal liability etc. Long term insurance provides cover in the event of death, disability, or critical illness etc.
If your claim dispute cannot be resolved between the insurer and yourself and your claim remains rejected or partly admitted, you have the option of approaching an Ombudsman who provides a free, independent, efficient, and fair dispute resolution through an alternative dispute resolution process, while applying the principles of fairness and equity. The Ombudsman’s main duty is to resolve complaints through mediation, recommendation and then, determination by making a ruling in the matter.
The Ombudsman is free to the public.
If your insurance claim is denied, it’s not necessarily the end. You can appeal internally and then escalate to an ombudsman or legal action if needed. Here are the steps:
In support of the above mentioned answer, if you believe that you have taken all the necessary steps, and your claim is still unfairly repudiated, you are entitled to seek legal advice to prosecute your claim. When it comes to unresolved and unfair disputes, there are several legal options that you can pursue depending on the nature of the dispute.
Such examples include but is not limited to:
Have a look at how Repudiation SA can help you here
To maintain a good standing with your insurance, make sure you meet all conditions by paying premiums on time, following contract terms, fulfilling obligations, reviewing and updating your policy as needed, and avoiding fraud or violations. If you do this, your insurer will cover qualifying claims as agreed.
In almost all insurance policies, the policy will contain a clause that requires notice of an event which could give rise to a claim or an actual claim to be given immediately or as soon as possible, but not later than 30 days. These clauses are usually inserted under the claims clause and /or in the conditions.
Failure to notify the insurer timeously of an event or actual claim in terms of the policy wording is material to the insurer’s business and constitutes a breach of the terms which you concluded with the insurer and such breach entitles the insurer to reject a claim and absolve itself from liability to pay the claim.
Yes, updating your policy details with your insurer is easy as a simple telephone call, a visit to their offices or filling in a form for online submission, provided that repudiation has not resulted in the rejection of the policy itself.
It is imperative to review and update your insurance coverage to ensure that you have sufficient protection. You have a duty to keep your insurer informed of any changes to your occupation, residence, or hazardous activities as the years progress as these are considered notifiable changes for several insurers.
Conditions are the terms that must be fulfilled by the policyholder to ensure that the policy remains valid. It is a key element in an insurance contract that defines the rights and obligations of the insured and the insurer. The performance or non-performance of a condition is considered crucial to the validity and enforceability of the claim. An example of this would be that the insured has a responsibility to notify the insurer of any material changes to the risk profile, such as change of risk address or change of occupation etc.
Warranties, on the other hand, are the statement made by the policyholder to the insurer that certain facts are true and that certain conditions will be met. Failure to comply with a warranty may result in the policy being voided and the insurer may be released from its obligations under the policy. An example of this would be that the insured must have a linked alarm system in order to enjoy theft cover or cover would be voided if the insured engages in hazardous activities.
LIFE INSURANCE CLAIMS (DEATH CLAIMS)
To start the claim process, you’ll need:
For unnatural deaths:
Once the claim is assessed and validated, the insurer will ask for:
Insurers aim to pay out claims promptly upon receiving all required documents, but it may take longer for investigations, especially for deaths within the first two years of policy or unnatural causes.
The insured or anyone mandated on the policy can submit a claim telephonically, via email or online depending on each insurers process. The claim needs to be reported as soon as possible and no later than 30 days from the date of the incident.
The following information may be required regarding the incident:
The following additional information/documentation may be required to process the claim:
The insurance company will then need to validate the claim to proceed, this includes the following:
Depending on the merits or quantum of the claim, an assessor, investigator, or loss adjuster may be appointed to assist with the validation process. The outcome of the claim is then discussed with the insured.
The insured or anyone mandated on the policy can submit a claim. The insurer needs to be notified as soon as possible but no later than 30 days from the date of the incident. For theft and hijacking, insurers may require a shorter time frame in which to be notified.
The following information may be required regarding the incident:
If there was a third party involved, the insurance company will require the third party’s names, full contact details, ID numbers, insurance details (if applicable) as well as their vehicle details. In addition thereto, the insurers legal department will also require a sketch and description of the incident and information of any witnesses who were present at the accident scene.
The following additional information and/or documentation will be required to process the claim:
The claim will then proceed to the assessment stage to determine whether the motor vehicle is drivable/non-drivable and full and a detailed assessment report will the produced.
The insurance company will then need to validate the claim to proceed, this includes the following:
Depending on the merits or quantum of the claim, an assessor (internal or external) may be appointed to assist with the validation process. The outcome of the claim will be discussed and supporting documents of the outcome will be communicated to the insured.
Firstly, you will need to properly check the details of your policy to see if the facts at hand fit the reason for the claim rejection. If you disagree with your insurer on the reason for the claim rejection, you can ask your insurer to conduct a full and fair review of its decision and if possible, you can provide additional information, documentation, or evidence to substantiate your claim.
You may also discuss the insurance companies internal review/appeal procedures. If you are still unhappy, you need to lodge a formal complaint with your insurer. Always remember to set out the facts as clearly as possible, in a logical order and stick to what is relevant including important details like your claim number or your policy number.
Should the insurer maintain the rejection of the claim, you have the option to approach Repudiation SA in this process.
Big insurance companies make their policies deliberately vague and confusing, to speed up their claims process. However, this means we may be able to fight to dispute your rejected claims.
If you believe your claim was wrongfully rejected, kindly fill in this form and one of our expert insurance claims consultants will get back to you as soon as possible.
If you believe your claim was wrongfully rejected, kindly fill in this form and one of our expert insurance claims consultants will get back to you as soon as possible.
noun [ U ] formal
‘When an Insurer rejects a claim or refuses to honour the contract / policy’
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