As consumer attorneys, we am well aware that many South African consumers are unhappy with their claims against insurance being rejected for invalid reasons.
If you are unhappy with the payment offer you receive, the National Financial ombud, which has replaced both the Ombudsman for Short-term Insurance and the Ombudsman for Long-term Insurance, will investigate and adjudicate eon your complaint. Here’s the process and our tips on how to get a better outcome:
- Don’t sign the offer without writing in that you will continue to pursue your claim for the rest of the claim amount.
- Ask them to send you a formal refusal.
- You first need to escalate your complaint within the insurance company- your policy documentation should give you the email address of the decisionmaker you need to approach with your complaint. Notify the decisionmaker that if there is not a favourable decision in response to your complaint, that you will approach the National Financial Ombud. First ask for the reason that your claim has been rejected or that your claim has not been fully paid- get that in writing from the insurer or the assessor. If there is an assessor involved, get a copy of his report. Then gather evidence to support payment of your claim which addresses the reason given by the insurer. You may need to get a report from a medical expert, and architect or a mechanic to support your claim which you can email along with your complaint.
- If this does not work, or still leaves you with an unpaid portion of our claim without a good reason, again, obtain a formal refusal from the insurer. Now you should report your claim to the ombud. You can lodge your claim here: https://nfosa.co.za/submit-a-complaint/. Attach all relevant documentation, especially the reason, and your reports or eyewitness account which demonstrates that the reason is not valid. You need to submit your complaint within 90 days from the date of the formal refusal.
- The ombud will appoint a case administrator, who will send your complaint to the insurer and obtain their response. It’s worthwhile following up with the case administrator so that this process is completed as quickly as possible. You will be able to respond to the insurer’s reply and it’s recommended that you do.
- Then an investigator will be appointed by the ombud to assess the case and provide a recommendation. You will have an opportunity to make further comments or provide more evidence or reports if you are unhappy with the recommendation. It is recommended that you do.
- You can find the NFO’s rules at https://ombudcouncil.org.za/wp-content/uploads/2024/02/NFO-Scheme-Rules-Final-approved-version-published-on-Ombud-Council-website.23-February-2024.pdf – draw them to the attention of the officials if they are not complying with their rules. You can also escalate a complaint to a team leader, or the Ombud, Edite Teixeira-Mckinon at Edite@nfosa.co.za.
- If you are given a deadline that is hard for you to meet, write to the official dealing with your case and request an extension of time- they grant extensions like that to the insurers on a regular basis, so they are unlikely to say no.
- Then the adjudicator will issue a final recommendation. If you are unhappy with it, write to the adjudicator insisting that your complaint be tabled before the escalation committee for a final ruling, stating that you do not accept the ruling. Despite Rule 9.3.1 of the ombud’s rules which does not require any reasons, the ombud asks for detailed reasons why it needs to be escalated, which can include more evidence or you can say they have not taken the evidence you have already provided into account.
- Keep following up by email or phone call.
- You will be informed of the decision as to whether the complaint will be escalated. If it is escalated, you will receive a final ruling. If you are unhappy with the final ruling, you can ask for permission to appeal to the ombud’s Appeal Tribunal. Unless you are legally trained, you may need an attorney to draft this for you. If you are granted leave to appeal (this is in the format of a ruling), you will after be provided with the appeal ruling.
Consumers often struggle to find an attorney to represent them against an insurer, and the problem is compounded when the insurer is a bank, such as Standard Bank Insurance. This is because attorneys aren’t allowed to act for an insurer or bank as well as against them as that means they have a conflict of interest, so consumers struggle to find attorneys who don’t have a conflict of interest since insurers and banks are of the biggest clients of law firms. We advise that you search for attorneys specialising in consumer law, as they are unlikely to have such a conflict.
By: Trudie Broekmann