How to avoid having a policy claim declined

South Africa’s life insurers paid out benefits amounting to a total of R578 billion in 2022. The figures, issued by the Association for Savings and Investment South Africa (ASISA), included life, disability, critical illness, and income protection policies claims.

Each year, Hollard Life Solutions processes an average of around 104,000 claims, and only a small portion of them are declined.

According to Hollard Life Solutions, the claims process is arguably one of the most crucial aspects of the policy cycle, and it is the insurer’s responsibility to make sure that this process is as seamless as possible for the policyholder. Avinash Baboolal, of Hollard Life Solutions highlights that to make sure claims are paid out on time without issues, policyholders should know what their policy entails.

He advises that from the onset, it is also important to be absolutely honest in your policy application. All medical conditions must be disclosed at the application stage to avoid having to provide additional information at the claim stage, which could delay the process, or have the claim declined. In particular, it is essential to declare a medical condition or symptoms of a medical condition prior to the commencement of the policy. Non-disclosure of an existing condition that is relevant to the incident being claimed is clear grounds for refusal to pay.

Furthermore, it’s important to ensure that your monthly premiums are paid when due to avoid the policy lapsing. Be aware of any waiting periods before the policy is in force. It’s also important to understand any policy exclusions, and what other conditions form part of the policy and to seek advice from your broker or insurer if unsure of anything regarding the policy and exclusions.
Claims are normally declined if these measures are not taken.

Policyholders who disagree with the decision by any insurance company to decline their claims may reach out to the Office of the Ombudsman for Long-term Insurance. The ombud deals mainly with repudiation disputes. It also looks into complaints about poor communication or poor service.

Often, clients raise concerns about not receiving adequate advice regarding policy requirements and conditions when their claims are denied. However, it is crucial that clients communicate these concerns up front with their advisors and also escalate these concerns with the insurer to ensure that they are satisfied with the onboarding process.

It’s crucial that clients review their policies on an annual basis with their broker to make sure that the policy is still relevant to their needs. Also important, is for policyholders to update beneficiary details and other information.