Receiving a Decline Letter
A claim decline letter is one of the most distressing documents a policyholder can receive, often arriving at a time of grief. Understanding what the letter says — and what your options are — is essential.
Typical Structure of a Decline Letter
Reference Details
The letter will reference your policy number, the claim number, and the date of the insured event. Verify that all details are correct.
The Decision
A clear statement that the claim has been declined. This is usually in the opening paragraph.
The Grounds
The insurer must explain why the claim was declined. Common grounds include:
- Waiting period: The insured event occurred within the waiting period
- Non-disclosure: Material information was not disclosed at the time of application
- Exclusion clause: The cause of death or disability falls within a listed exclusion
- Policy lapse: The policy was not active at the time of the event due to non-payment of premiums
- Fraud: The insurer believes the claim is fraudulent
Your Options
The letter should inform you of your right to dispute the decision and provide the contact details for the internal complaints process and the relevant ombud.
What to Do When You Receive a Decline
- Read the letter carefully. Identify the specific clause or condition the insurer is relying on.
- Check your policy schedule. Verify that the insurer's interpretation matches the written terms.
- Gather evidence. If you believe the decline is unfair, collect medical records, correspondence, and any documents that support your position.
- Lodge an internal complaint. Write to the insurer's complaints department, clearly stating why you believe the decision is wrong.
- Escalate if needed. If the internal process does not resolve the matter, contact the Ombud for Long-term Insurance at ombud.co.za.
Time Limits
There are time limits for disputing a claim decline. The ombud typically requires that complaints be lodged within three years of the event. Do not delay.
Contributed by Socinga Africa Holdings (FSP 46620). This is educational content only and not financial advice.