INSURANCE CLAIMS PROCEDURES

This is the procedure that you as a client should follow when you want to lodge a claim.

NB: Failing to follow these procedures, you will break the conditions of your policy that may INVALIDATE your claim.

THE CLAIMANT MUST  

  1. Immediately effect temporary repairs, necessary to prevent further loss, damage or injury.
  2. Immediately notify the police following loss or damage by theft, attempted theft, malicious damage and obtain a case reference number.
  3. Provide your broker with a claim form with the full details as soon as possible after the event, but not later than 30 DAYS after an occurrence. YOUR CLAIM MAY BE REJECTED BY THE INSURERS AT THEIR DISCRETION, WHEN FAILING TO DO SO.
  4. Provide your broker with all the correct information and evidence, including quotes and estimates that the insurers may require.

DO NOT UNDER ANY CIRCUMSTANCES

  1. Effect full repairs without your insurers consent.
  2. Admit, negotiate or settle any claim without your insurers permission in writing.
  3. Abandon your property

 

CAN A CLIENT LOSE MONEY?

It must be noted that your policy is not an investment or savings product, so the risk that you may get out less money than you put in, will not be relevant.

If you cancel your policy with an insurer, the cover will fall away, and payments for past cover periods will not be refundable.

WHAT WILL BE THE EFFECT ON YOUR POLICY IF YOU CLAIM

Cover will remain in force after a claim was paid.

The insurer has the right to increase your premiums, or reduce your cover or even cancel your policy if increased claims occur.

 

 

 

Claim rejection

How can my insurer reject my claim?

  1. If you have been advised that your claim has been rejected, then insist on seeing a formal letter of rejection from the Insurer, not just what your Broker has told you or written to you, but the actual communication from the insurer formally rejecting the claim.
  2. The letter should convey to you clearly the detailed grounds upon which the Insurer bases its rejection of the claim. If the grounds are not clear, ask for clarity, and if you do not receive it, this is probably in itself a good reason to approach the Ombudsman or your legal advisors.
  3. Read those grounds carefully in conjunction with the Policy itself. If you are not in receipt of the Policy wording then you are entitled to one from your Broker or your Insurer.
  4. There are numerous grounds on which an insurer may reject a claim, depending on the type of claim and the extent of the cover being provided. You Must bear in mind that the intention of an insurance contract not to cover every loss under all circumstances. Further, by the very nature of it, an insurance contract, like all other contracts, contains terms and conditions, which allows the insurer to exclude liability in certain instances.

What steps do I take once a claim has been rejected?

  1. Having examined the Policy and the grounds of repudiation you must make a preliminary decision as follows: -
  • Are the facts set out as justifying the ground of rejection correct?
  • Do those facts, in terms of The Policy conditions or exclusions, entitle the Insurer to reject
  • If the answer to either, or both, of these questions is “No”, then you may well have valid grounds for complaint. However, please bear in mind that where facts are in dispute, that usually means the issue can only be determined by evidence and you need to consider the strength of the evidence in support of your version of the facts, and against the Insurer’s version.

 Before considering what step to take next, look at it OBJECTIVELY and put to yourself the questions posed. Finally, don’t delay in dealing with the matter. The Policy contains a Clause which states that you may make representations to the insurer and request further information regarding the rejection. Further if you don’t institute legal proceedings or lodge a complaint with our office within a certain period after the rejection then you are precluded from doing so thereafter.

(NPC – Registration Number 2000/030638/08)

Ombudsman For Short Term Insurance ׀ 2012 © Copyright. All Rights Reserved.

Tel. 011 726-8900 ׀ Fax. 011 726-5501 ׀ Sharecall: 0860 726 890 ׀ E-mail. info@osti.co.za

Sunnyside Office Park, 5th Floor, Building D, 32 Princess of Wales Terrace, Parktown

Postal Address Po Box 32334 Braamfontein, 2017

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