Few moments are more frustrating than opening a repudiation letter after a loss you believed was covered. The good news is that a declined claim is rarely the end of the road. South African law gives policyholders clear rights, strict timelines, and multiple avenues to challenge an insurer’s decision. This step-by-step guide explains what to do next, how to prepare a strong challenge, and where to escalate if you remain unhappy with the outcome.
Quick disclaimer: This article provides general information, not legal advice. Complex or high-value disputes warrant professional guidance.
1) First things first: pause, read, and organise
Do not ignore the letter. South African Policyholder Protection Rules (PPRs) impose very specific deadlines after a rejection. Missing them can extinguish your right to sue. Your repudiation letter should explain why the claim was declined, how to escalate internally, how long you have to make representations (not less than 90 days), and what time limits apply to litigation or the Prescription Act if no time-bar is in the policy. (Government of South Africa)
Create a file (digital and physical) with:
- Your policy wording, schedule, endorsements, excesses, and any renewal notices.
- All claim documents: forms, photos, invoices, reports, assessor notes (if shared), police case numbers, affidavits.
- The rejection letter and any emails, phone call notes, or WhatsApp messages.
- A simple chronology of events with dates.
This organisation matters, because the insurer must respond to your formal representations within 45 days once you escalate internally. You will want to make that submission complete and precise the first time. (Government of South Africa)
2) Understand the common reasons for rejections
Insurers decline claims for a handful of recurring reasons. Knowing which bucket you are in helps you respond effectively.
- No cover for the event
The loss falls outside the insured perils (for example, gradual deterioration or wear-and-tear, which most policies exclude). - Policy exclusions apply
Examples include driving under the influence, unlicensed driving, illegal activities, or specified security conditions not met (for instance, alarms not armed). - Breach of policy conditions
Late notification, failure to supply documents, or not taking reasonable steps to prevent further loss. - Material non-disclosure or misrepresentation
Information at inception or renewal was withheld or misstated and would have affected underwriting. - Unpaid premium or lapse
The policy was not in force on the date of loss. - Underinsurance (average clause)
This usually reduces settlements rather than a full rejection, but it is worth flagging because it drives many disputes. - Waiting periods and exclusions in long-term or microinsurance
For life, disability, and funeral benefits there may be defined waiting periods or exclusions set by the long-term PPRs and product rules. (Government of South Africa)
Identify the exact ground relied upon in your letter. If the reasons are vague or missing, you are entitled to a plain-language explanation “in sufficient detail to enable you to dispute such reasons,” plus information about your right to escalate internally, complain to the ombud, and any time-bars that apply. (Government of South Africa)
3) Know your rights and timelines
The Policyholder Protection Rules set minimum standards for all insurers:
- Written reasons within 10 days: The insurer must notify you in writing of its decision to accept or reject your claim within a reasonable period, and if rejected, must issue written reasons within 10 days of the decision. (Government of South Africa)
- At least 90 days to make representations: You must be given not less than 90 days from receipt of the rejection to submit your written representations under the insurer’s internal escalation and review process. (Government of South Africa)
- 45-day insurer response to your representations: Once you submit representations, the insurer must respond within 45 days with a final position. (Government of South Africa)
- Litigation time-bar cannot run during your 90-day window: For policies issued on or after 1 January 2011, the contract’s time-bar must give you at least six months after the 90-day representation period to issue summons if you still disagree. The 90-day period itself cannot be counted in the time-bar. (National Treasury of South Africa, Government of South Africa)
- Courts can still condone late action: Even after a time-bar expires, courts may condone non-compliance if good cause exists and the clause is unfair in the circumstances, but do not rely on this without legal advice. (Government of South Africa, Pinsent Masons)
These protections exist under both the short-term and long-term PPR frameworks, which codify fair treatment and transparency for policyholders. (Government of South Africa, National Treasury of South Africa)
4) Use the insurer’s internal escalation process (and make it count)
You must use the insurer’s internal claims escalation or review process before going to an ombud. Here is how to make that step effective.
A. Build a tight case file
- Pinpoint the exact policy clause the insurer relied upon.
- Contrast it with your facts and evidence.
- If non-disclosure is alleged, show why the information was not material, was actually disclosed, or could not reasonably have been known at inception.
- If a condition precedent is cited (for example, alarm activation), show compliance or explain why non-compliance was immaterial to the loss.
B. Submit formal written representations
Your letter should:
- Reference the policy number, claim number, date of loss, and the rejection letter date.
- Summarise the dispute in one paragraph.
- List and attach evidence (photos, reports, statements, invoices).
- Quote the precise policy wording and explain, clause by clause, why the decision is wrong or unfair.
- Request reconsideration and a written response under Rule 17.6.5 within 45 days. (Government of South Africa)
Tip: If you worked through a broker or adviser, ask for help. Where poor advice or intermediary conduct contributed to the problem, note that you may have a FAIS complaint as a separate route (see Section 6 below). (FAIS Ombud)
5) Escalate externally if needed: who to approach, and when
South Africa has specialist ombuds and a national umbrella scheme. Choose the right one for your product and issue.
A. Short-term (non-life) insurance – cars, homes, business, travel
Ombudsman for Short-term Insurance (OSTI) handles disputes about short-term policies and claim outcomes. It is a free, alternative dispute resolution forum. Insurers that subscribe are bound by rulings; consumers are not and remain free to litigate. Time-bar and policy deadlines still matter, so file early. (Ombud Council)
B. Long-term insurance – life, disability, funeral, credit life
Services historically provided by the Ombudsman for Long-term Insurance (OLTI) now fall under the National Financial Ombud (NFO) umbrella. You can submit long-term insurance complaints through NFO, which provides information, guidance, and the complaint gateway. (NFOSA)
C. Advice or intermediary conduct – mis-selling, bad advice, disclosure failures
If your dispute relates to the advice you received (for example, you were sold the wrong cover or critical disclosure was omitted), you may complain to the FAIS Ombud. You must first give the firm six weeks to resolve the complaint. If you receive a final response or six weeks pass without resolution, you have six months to lodge the complaint with the FAIS Ombud. (FAIS Ombud)
D. How the NFO coordinates
The NFO provides a gateway and FAQs explaining typical timelines and that insurers are given six weeks to respond to first complaints. Use this to plan your escalation and diarise dates. (NFOSA)
6) Build a persuasive ombud complaint
Whether you approach OSTI, the NFO (for long-term), or the FAIS Ombud, present a crisp, evidence-led case.
Include:
- Your details, insurer name, policy and claim numbers, dates, and the product type.
- The repudiation letter.
- A one-page summary of facts and why the decision is wrong (or unfair) with policy clauses quoted.
- Evidence bundle: photos with timestamps, expert reports, medical or police documents, invoices/quotes, witness statements, and all correspondence.
- What outcome you seek (for example, claim payment of Rxx,xxx; re-assessment; application of average instead of rejection; waiver of a technicality that did not affect risk).
Remember: Ombuds consider the law and principles of fairness and equity, and can recommend or determine outcomes according to their rules. For OSTI, subscribers are bound by final rulings, while you may still reject the outcome and litigate. (Ombud Council)
7) When to consult an attorney
You should seek legal advice when:
- The amount in dispute is high and delay risks a time-bar.
- There are complex coverage issues or factual disputes.
- You are close to the end of the six-month litigation window that follows the 90-day representation period. (National Treasury of South Africa)
Courts have confirmed that time-limitation clauses can be enforceable even in difficult circumstances. Do not gamble with deadlines. (Pinsent Masons)
8) Practical templates and checklists
A. Internal representations letter (editable outline)
Subject: Claim Rejection – Representations under Rule 17.6.3 and 17.6.5
Policy: [Number] | Claim: [Number] | Loss date: [Date] | Insurer letter dated: [Date]
- Summary
I submit representations against your decision to repudiate my claim on [date]. The decision relies on [clause / reason].- Policy wording and analysis
Clause [quote] is cited. On the facts, [brief facts], the clause does not apply because [reasons]. Alternatively, the alleged non-compliance was immaterial to the loss.- Evidence
Attached: [list documents]. These support that [key point].- Outcome requested
Reconsider and pay the claim (R[amount]) or provide reasons in full.- Process and timelines
These representations are submitted within the 90-day period. Kindly provide your written decision within 45 days, as required. (Government of South Africa)Yours faithfully,
[Name, ID, contact details]
B. Evidence pack checklist
- Photos or video with timestamps and geolocation where possible.
- Expert or assessor reports; repair quotes; invoices; proof of ownership and value.
- Police case number, medical reports, or affidavits where relevant.
- Proof of compliance with security requirements (alarm certificates, activation logs).
- Proof of premium payments and policy in force.
- Any broker or adviser communications about cover.
C. Timeline diary (example)
- Day 0: Receive rejection letter (note exact date received).
- Day 1–30: Gather evidence; obtain policy documents; draft representations.
- By Day 90: Submit representations to insurer’s escalation unit.
- Within 45 days of submission: Insurer must respond with final decision.
- Thereafter: If still rejected, consider ombud complaint and diarise court time-bar (not less than six months after the 90-day period). (Government of South Africa, National Treasury of South Africa)
9) Special notes for long-term and microinsurance claims
Long-term benefits (life, disability, funeral, credit life) follow their own PPRs. Among other consumer protections, the rules limit certain exclusions and define claims-handling expectations. For example, waiting periods and suicide exclusions are regulated, and claims decisions must be given promptly after required documents are received for microinsurance and funeral products. If your long-term claim is rejected on the basis of a waiting period or exclusion, verify that the rule actually permits that exclusion and that it has been applied correctly. Then escalate through NFO if required. (Government of South Africa)
10) Frequently asked questions
Q1: Does submitting an ombud complaint pause my right to sue?
Time-bars in policies interact with the PPRs. The 90-day representation period may not be counted in a contractual time-bar, and you must get at least six months after that to institute legal action. Policies and facts vary, so if you are close to a deadline, obtain legal advice and consider issuing summons to protect your rights while an ombud process continues. (National Treasury of South Africa)
Q2: The rejection letter is short on detail. Can I demand more?
Yes. The PPRs require plain-language reasons with enough detail to dispute the decision, plus clear signposting of the internal review process, ombud options, and any time-bars or prescription periods. Ask for a compliant letter if necessary. (Government of South Africa)
Q3: Do I have to complain to the insurer before the FAIS Ombud?
Yes. For advice or intermediary conduct complaints, you must give the firm six weeks to respond, and then you have six months to file with the FAIS Ombud after a final response (or after six weeks with no resolution). (FAIS Ombud)
Q4: Can an insurer enforce a very short time-bar (for example, 30 days to sue)?
No. For policies from 1 January 2011, the time-bar must exclude the 90-day representation period and must grant at least six months thereafter to institute legal action. Courts may also condone late action where fairness demands, but do not rely on this. (National Treasury of South Africa, Government of South Africa, Pinsent Masons)
Q5: My claim was reduced, not rejected, because of “average.” What now?
Underinsurance typically leads to a proportional reduction, not a full repudiation. Ask the insurer to show how the sum insured compares to replacement value and how the average calculation was done. If you disagree, challenge it through the same internal process and, if needed, OSTI.
11) Prevention beats cure: reduce the risk of rejection
- Keep your policy up to date. Tell your insurer about changes in use, security, address, or drivers.
- Insure for correct values. Avoid underinsurance by reviewing sums insured annually.
- Document everything. Keep proof of ownership, maintenance, and security compliance.
- Report promptly and follow procedures. Late notification and missing documents are common pitfalls. (fanews.co.za)
- Work with a competent adviser or broker. Good advice ensures you buy appropriate cover and meet conditions. Where advice fails, the FAIS route exists. (FAIS Ombud)
12) Where to get help
- Internal escalation team at your insurer: Use the 90-day window to submit representations; expect a written decision within 45 days. (Government of South Africa)
- Ombudsman for Short-term Insurance (OSTI): Motor, home, business, and other non-life claim disputes; rulings bind subscribing insurers; you remain free to litigate. (Ombud Council)
- National Financial Ombud (NFO) – Long-term insurance complaints: Life, disability, funeral, credit life; NFO now houses the long-term ombud services. (NFOSA)
- FAIS Ombud: Advice/intermediary complaints; six-week internal attempt first, six months to lodge thereafter. (FAIS Ombud)
13) The Rateweb bottom line
A rejection is not a final verdict. South African conduct standards force insurers to be transparent, give you a 90-day opportunity to make your case, respond within 45 days, and honour fair processes. Where disagreement persists, the ombud system offers a no-cost path to a reasoned outcome, and the courts remain open for litigants—subject to the six-month post-representation time-bar and prescription rules. If you prepare a focused, evidence-rich submission and follow the timelines, you maximise your chances of overturning a bad decision or reaching a fair settlement. (Government of South Africa, National Treasury of South Africa)
References (for readers who want the source rules)
- Policyholder Protection Rules (Short-term) – Rule 17.6 on decisions, 90-day representations, 45-day response, and time-bars. (Government of South Africa)
- Policyholder Protection Rules (Long-term) – parallel provisions and long-term product protections. (National Treasury of South Africa)
- Court and commentary on time-bars in insurance contracts. (Pinsent Masons)
- FAIS Ombud process and timelines. (FAIS Ombud)
- National Financial Ombud (NFO) – long-term complaints gateway and FAQs. (NFOSA)
William Dube is a finance and economic news expert with over 10 years of experience in economic anaylsis, financial product assessment and market analysis. With a numerous certificates from prestigious universities including but not limited to Yale University and the University of Pennyslivenia. William specializes in providing insightful news developments in South Africa and commentary on investment strategies, risk management, and global economic trends.
You can contact him on william@rateweb.co.za
