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How to file an insurance claim in South Africa

How to file an insurance claim in South Africa

There are various reasons why insurance claims are rejected. Sometimes it’s due to missed premium payments, or contractual technicalities, or claimants taking fraudulent chances. Sometimes, though, insurance claims are denied on the basis that the insured person took too long to get their paperwork in.

When in doubt, refer to your policy

The claims process depends on your insurer. Some ask you to file the claim over the phone. They will then send you a claim form for you to complete and send back along with supporting documents. Others may ask you to submit your claim online.

The process also depends on what type of claim you are making. If you’ve had an accident, you’ll need to provide full details of the accident along with details of other parties involved. Depending on the seriousness of the incident, you may also need to contact the police and send the police report to the insurer. It’s also a good idea to take pictures and any witness statements to support your claim.

 What must be established to trigger coverage under an insurance policy?

Insurance contracts have certain specified provisions and clauses which have to be fulfilled so that the claim can be considered valid. Such clauses have to be clearly stated in the policy document at the time of commencement of the contract for the information of the policyholder. Waiting periods in which the insurance benefits do not apply is also a type of exclusion. An example of general exclusions that are common would be when a policyholder causes the damage themselves either deliberately, or by doing something dangerous or illegal.

The insured must provide all material information in its possession to enable the insurer to assess the merits and quantum of the claim and whether the incident is included under the cover. The insurer may request specific information from the insured on a claims form or otherwise. The insurance company may investigate the incident and damage by appointing an assessor to establish the validity and value of a claim.

It is important to understand the value for which you are covered as well as the difference between replacement value and market value. Without a clear understanding of the difference between these two definitions, a policyholder may face the hard reality at claim stage when the insurer will inevitably apply an average and the owner’s claims will not be paid out 100%.

Timing is important

There are no statutory requirements (in terms of an Act) limiting the time in which notice of an insurance claim must be given. Insurance companies can therefore determine a time period in their insurance contract with a client.  Typically, the insurance policy requires the insured client to provide notice of a claim as soon as possible, and provides for a reasonable time period in which notice must be given. The insurance company does not need to establish prejudice to reject coverage on the basis of late notification. Some policies, for example claims-occurring policies, require notice of events likely to give rise to a claim.

If you need to submit a claim, do it as soon as possible. Some insurers have a claims window that you must file your claim within, failing which your claim may not be paid out. Furthermore, in South African law, there’s a term called ‘prescription’, which is basically an expiry date before which you have to file your claim. There are practical reasons for requiring insured person’s to submit their claims speedily, such as investigations and admin as well as legal steps that may have to be taken, which can all take up a lot of time.

Need advice on your insurance matter?

If you need assistance with an insurance matter, where a claim has been denied, rejected or repudiated feel free to contact us at Paul du Plessis Attorneys on 012 809 1588 or send an e-mail to paul@pauldup.co.za