Quick answer
Ask the insurer to state the contract, clause, facts and evidence behind every rejection ground. Then ask what the internal review can reconsider, which records remain missing, what period applies and which external route is available. Direct separate questions to a broker, expert, ombud or lawyer according to that person's role.
How to use this guide
The purpose is to obtain a reviewable position, not to provoke a new informal explanation that cannot be traced to the decision.
Questions for the insurer
Request the complete schedule, wording and endorsements that governed the event. Ask when they became effective and how they were delivered. For each ground, request the exact definition, exclusion, condition, disclosure term, premium provision or benefit formula relied on.
Ask which facts are accepted, disputed or considered unproved. Which claim document, report, photograph, statement or account influenced the finding? Is the result a complete rejection, a partial decision, a quantum calculation or a request for further proof?
Questions about internal review
Ask where the complaint must be sent, what information it needs, when receipt will be acknowledged, who decides it and whether a written final response will identify all reasons. Confirm the claim and complaint references.
Ask whether supplying specified evidence will lead to reconsideration and whether the insurer says any deadline continues during the review. Preserve the answer, but obtain independent advice if the legal effect of a period matters.
Questions for the broker or adviser
Ask what advice, disclosures and product documents were supplied; which questions were asked during application; what answers were recorded; and whether changes were communicated. Ask for the needs analysis or record of advice where relevant.
Do not ask an intermediary to decide contractual coverage if the insurer owns that decision. Conversely, a claim complaint may not resolve a separate allegation about unsuitable advice or a representation made during sale.
Questions for assessors and experts
Identify who instructed the expert, the issue referred, inspection date, evidence reviewed, assumptions and methodology. Ask whether the full report, images, measurements or calculation can be disclosed. Record any limitation in access.
Before commissioning a competing report, ask what proposition needs expert evidence and whether its likely value justifies the cost.
Questions about the National Financial Ombud
Confirm whether the institution is a participating entity, whether the complaint belongs in the life or non-life division, whether internal procedures have been completed and whether the matter is within the current scheme rules. Ask what mandate is needed if a representative files it.
Check required evidence, receipt confirmation, confidentiality, time rules and the effect of existing legal proceedings. Do not assume that the NFO, FSCA and another ombud perform interchangeable roles.
Questions for a lawyer
Provide the original claim, decision, policy set and chronology, then ask:
- What is the insurer's strongest contractual or factual point?
- What is the policyholder's strongest answer?
- Which evidence gap matters most?
- Is there a serious fraud, disclosure, causation or expert issue?
- What date could affect the available remedy?
- Which forum can grant the result sought?
- Should any statement, report, settlement or release be reviewed before submission or signature?
- What bounded work and fee are proposed for the next decision?
Questions about remedy and settlement
Ask how the claimed amount was calculated, whether an excess or limit applies and whether interest, costs or other benefits are included. If an offer is made, ask whether it is full and final, which parties it releases and what happens to the policy or complaint afterward.
Record the answers
Put every question and answer in a dated log with source, reference and next action. Distinguish a written decision, an informal call and your own inference. If an answer changes, keep both versions and request clarification.
Practical next step
Apply the rejected insurance claim: questions to ask checklist to the next submission or consultation. Before the consultation, confirm how the adviser wants the policy and repudiation material arranged and flag any response or prescription date at the top.
FAQs
Can I ask the insurer for the exact clause it relied on?
Yes. Ask for the operative policy version, page, clause, material facts and records underlying each stated reason.
What should I ask an assessor?
Clarify the instruction, inspection date, materials considered, methodology, factual assumptions and whether the report supplied to the insurer is available.
What should I ask about an ombud complaint?
Confirm participant, division, jurisdiction, internal complaint status, time position, required documents and whether legal proceedings affect the route.
Should I ask whether the claim will definitely succeed?
Ask for reasoned strengths, weaknesses, evidence gaps and route options. No responsible adviser can guarantee the insurer, ombud or court outcome.
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Source notes
Legal note
This article is general legal information for South African readers. It is not legal advice. Speak to a qualified legal professional about your specific facts before taking action.