Claims

An insurance claim is a formal request made by a policyholder to their insurer for payment or compensation following a loss or event covered by their policy.

When something goes wrong like your car is stolen, your home floods, you are involved in an accident, or you suffer a disability, you submit a claim to your insurer as the mechanism for activating the cover you have been paying for.

The insurer assesses the claim against the terms and conditions of the policy and, if valid, makes a payment to settle the loss: either directly to you, to a third party (such as a panel beater or builder), or to a service provider on your behalf.

At Ambiton, we manage the claims process on your behalf from start to finish so your first call when something goes wrong is to us, not to the insurer.

The claims process in South Africa typically follows these steps:

1. Notify your broker or insurer: Contact Ambiton as soon as possible after the incident. Prompt notification is important — most policies require you to notify the insurer within a reasonable time, and delays can complicate the process
2. Provide documentation: You will need to supply relevant documentation depending on the type of claim. This typically includes a completed claim form, a copy of your identity document, proof of ownership or value, photographs of the damage, and in some cases a police report or incident report
3. Assessment: The insurer appoints an assessor or loss adjuster to investigate and assess the validity and quantum of the claim. For smaller claims, this may be done remotely; for larger claims, a physical inspection is typically required
4. Decision: The insurer accepts, partially accepts, or repudiates (rejects) the claim based on the assessment and the policy terms
5. Settlement: If accepted, the claim is settled by payment to you, repair by an approved service provider, or replacement of the damaged item

At Ambiton, we manage steps 1 through 5 on your behalf: submitting the claim, following up with the insurer, liaising with the assessor, and ensuring the settlement is fair and prompt.

Submitting a claim through Ambiton is straightforward.

Contact us as soon as possible after the incident by:

Phone: 041 581 7170 (business hours)
After hours emergency: 078 451 4284
Email: marketing@ambiton.co.za
Online: Use our claims submission form on the website

When you contact us, have the following information ready where possible:

• your policy number,
• the date and nature of the incident,
• a description of the loss or damage,
• and any relevant supporting information such as a SAPS case number.

We will guide you through the rest of the process, advise you on what documentation is required, submit the claim to the insurer on your behalf, and keep you updated at every stage until settlement.

The documentation required depends on the type of claim. As a general guide:

• All claims: Completed claim form, copy of identity document, copy of policy schedule
• Motor vehicle claims: South African Police Service (SAPS) case number (for theft, hijacking or third-party accident), photographs of the damage, driver’s licence, vehicle registration documents
• Home contents and personal all-risk claims: List of stolen or damaged items with approximate values, proof of ownership where possible (receipts, photographs, bank statements), SAPS case number for theft
• Building claims: Photographs of the damage, contractor quotes for repairs, SAPS case number where applicable (e.g. malicious damage)
• Life and disability claims: Death certificate or medical evidence of disability, completed insurer claim form, identity documents of claimant and beneficiaries

We will guide you through exactly what is needed for your specific claim and help you compile the documentation correctly to avoid unnecessary delays.

For many types of claims in South Africa, a police report (SAPS case number) is required or strongly recommended. Specifically:

• Theft of a vehicle: A SAPS case number is almost always required
• Hijacking: A SAPS case number is required
• Home burglary or theft: A SAPS case number is required
• Third-party vehicle accidents: A SAPS case number is required if there are injuries, if the other driver does not stop, or if liability is disputed
• Malicious damage to property: A SAPS case number is required

For accidents where only your own vehicle is damaged and no other party is involved, a police report may not always be required but it is always advisable to report any incident
to the police, both to comply with your policy requirements and to protect yourself from subsequent disputes.

Check your policy wording or contact Ambiton before assuming a police report is not needed. Failing to report an incident that your policy requires you to report can result in your claim being repudiated.

Managing an insurance claim without professional support puts you at a significant disadvantage. Insurers deal with claims every day, most policyholders deal with a major claim once or twice in a lifetime. The knowledge gap is substantial.

A broker adds value in the claims process by:

• Knowing exactly what documentation is required and ensuring it is submitted correctly the first time
• Understanding the policy wording and identifying grounds for the claim that the policyholder may not be aware of
• Maintaining relationships with insurer claims departments and assessors, which facilitates faster resolution
• Negotiating on your behalf if the insurer’s initial assessment or settlement offer is below what the policy entitles you to
• Escalating disputes formally and effectively if a claim is unfairly repudiated
• Providing a buffer between you and the insurer during what is often a stressful period

At Ambiton, claims handling is one of our core services, not an afterthought. We believe that a broker is only as good as the support they provide when a client actually needs to claim.

The time it takes to settle an insurance claim depends on the type and complexity of the claim:

• Simple claims: such as a windscreen replacement or a straightforward theft claim with all documentation in order, can often be settled within a few days to two weeks
• Motor vehicle accident claims typically take two to four weeks, depending on the extent of the damage and the availability of parts
• Building and structural damage claims can take four to eight weeks or longer, particularly where a specialist assessor or quantity surveyor is required
• Life and disability claims typically take four to eight weeks from submission of all required documentation
• Complex or disputed claims can take significantly longer, particularly where liability is contested or an investigation is required

At Ambiton, we actively follow up on all open claims and push for prompt resolution.

If a claim is taking longer than expected, we escalate on your behalf and keep you informed at every stage.

Insurance claims are denied (repudiated) for a number of reasons. The most common in South Africa include:

• Non-disclosure: Failing to disclose material information when taking out the policy such as previous claims, modifications to your vehicle, or the true use of the insured item
• Exclusions: The cause of the loss falls under a policy exclusion for example, wear and tear, gradual deterioration, or an event specifically excluded from cover
• Failure to take reasonable precautions: Leaving a vehicle unlocked, failing to maintain a building, or not having prescribed security in place
• Late notification: Failing to notify the insurer within the required timeframe
• Misrepresentation: Providing incorrect information in the claim form or to the assessor
• Policy not in force: Premiums were in arrears and the policy had lapsed at the time of the loss
• Underinsurance: The insured value is significantly below the replacement value, triggering a proportional reduction in the claim (average clause)

If your claim has been denied, contact Ambiton immediately. We will review the repudiation letter, assess whether the grounds are valid, and advise you on whether and how to dispute the decision.

If your claim is rejected, you have several options:

• Internal dispute: Request that the insurer formally review the repudiation through their internal complaints process. This should always be your first step
• Broker intervention: If you are an Ambiton client, contact us immediately. We will assess the grounds for repudiation, engage with the insurer on your behalf, and advocate for a fair outcome. In many cases, claims initially rejected can be successfully disputed
• Ombudsman for Short Term Insurance (OSTI): If the internal process does not resolve the dispute, you can escalate to the OSTI, which provides a free,
  independent dispute resolution service. The OSTI can investigate the matter and its rulings are binding on the insurer up to a specified financial limit
• FAIS Ombud: For complaints relating to the advice you received from your broker or insurer, the FAIS Ombud handles disputes between clients and financial services providers
• Legal action: As a last resort, you may pursue the matter through the courts, though this is rarely necessary given the effectiveness of the ombudsman process

Time limits apply to escalations so do not delay in seeking assistance if your claim has been rejected.

Yes, in most cases, making an insurance claim will affect your premium at renewal. How much it is affected depends on:

1. The number of claims you have made: Multiple claims in a short period will have a more significant impact than a single claim
2. The type of claim: At-fault claims (where you are responsible for the loss) typically have a greater impact than non-fault claims (e.g. a third party hit your vehicle while it was parked)
3. The value of the claim: Large claims have a greater premium impact than minor ones
4. Your insurer and their specific underwriting approach

Many insurers offer a “no-claims bonus” that reduces your premium over time if you do not claim. Making a claim will typically reduce or eliminate this bonus.

Before making a small claim, it is worth weighing the cost of the excess against the potential premium increase at renewal. For a minor loss that is only slightly above your excess, it may be more cost-effective to absorb the loss yourself.

An Ambiton adviser can help you make this assessment.

In most cases, short term insurance claim payouts in South Africa are not subject to income tax. They are treated as compensation for a loss rather than as income. You are being restored to the position you were in before the loss, not enriched.

However, there are exceptions:

• If the payout exceeds the actual replacement cost or original cost of the asset, the excess may be subject to capital gains tax
• Business interruption insurance payouts, which replace lost revenue or profits, are generally treated as taxable income in the hands of the business
• If a business has claimed the insurance premium as a tax-deductible expense, the corresponding claim payout may be included in taxable income

For personal short term insurance claims (home, vehicle, contents), the payout is generally not taxable. If you are uncertain about the tax treatment of a specific claim payout, consult a tax adviser.

A third party insurance claim arises when you claim against another person’s insurance (or they claim against yours) following an incident in which one party caused loss or damage to the other.

In the context of motor vehicle insurance, a third party claim typically means:

• You were involved in an accident that was the other driver’s fault, and you are claiming against their insurer for your vehicle damage or injuries
• Alternatively, another person is claiming against your insurer because you caused damage to their vehicle or property

Third party claims can be more complex than first-party claims because liability must first be established. If the other party’s insurer disputes their client’s liability, the process can be protracted.

At Ambiton, we assist our clients in navigating third party claims whether you are the claimant or the respondent. We will advise you on your rights, manage communication with both insurers, and ensure the process is handled correctly.

If you are involved in an accident caused by an uninsured driver, your options depend on the type of cover you have:

• If you have comprehensive motor insurance: Your own insurer will typically pay to repair or replace your vehicle, subject to your excess. You may lose your no-claims bonus. Your insurer may then attempt to recover the cost from the uninsured driver through subrogation
• If you have third party only cover: You are not covered for damage to your own vehicle caused by an uninsured driver. You would need to pursue the uninsured driver directly through the courts
• Road Accident Fund (RAF): If you or your passengers suffered bodily injuries in the accident, you may be able to claim from the Road Accident Fund regardless of whether the other driver was insured. The RAF covers claims for loss of income, general damages, and medical expenses arising from motor vehicle accidents on South African roads

Given the high number of uninsured drivers on South African roads, comprehensive motor insurance and an understanding of RAF claims are both important.

Contact Ambiton if you are in this situation, we will advise you on the most appropriate course of action.

The Road Accident Fund (RAF) is a statutory body established by the Road Accident Fund Act that compensates victims of motor vehicle accidents on South African roads for bodily injuries sustained. It does not cover property damage.

The RAF covers:

• Loss of income or support (for the injured party or dependants of a deceased victim)
• General damages for pain and suffering, disfigurement, and loss of amenities of life (subject to a serious injury assessment)
• Medical expenses not covered elsewhere

RAF claims can be made against the identified driver’s fund, or against the RAF directly where the driver is unidentified (e.g. a hit and run). The process involves a formal assessment of the injury, documentation of the accident, and submission of a claim.

RAF claims can be complex and are subject to prescription (a three-year time limit from the date of the accident).

If you or a family member has been injured in a motor vehicle accident, contact Ambiton for guidance, and consider engaging an attorney who specialises in RAF claims.

An excess (also called a deductible) is the portion of a claim that you are required to pay yourself before your insurer pays the remainder. It is your financial contribution to each claim.

For example, if your car is damaged in an accident and the repair costs R25,000, and your policy has an excess of R3,500, you pay R3,500 and your insurer pays R21,500.

Excesses serve two purposes: they reduce the cost of insurance (the higher your excess, the lower your premium) and they discourage small, nuisance claims.

Some policies have multiple excesses that apply in specific circumstances, such as:

• A standard excess on all claims
• An additional excess for drivers under 25
• An additional excess if the driver is not listed on the policy
• A specified excess for specific causes of loss such as hail damage

It is important to understand your excess before you claim, so you can make an informed decision about whether to claim or absorb the cost yourself.

Ambiton reviews excess structures with our clients as part of the annual policy review.

Underinsurance occurs when the insured value of an asset is less than its actual replacement cost. It is one of the most common and damaging issues in South African short term insurance, and it can significantly reduce your claim payout.

Most policies contain an “average clause” (also called co-insurance). This means that if you are underinsured, your insurer will only pay a proportional share of the claim equal to the ratio of the insured value to the actual replacement value.

For example: if your home contents are worth R500,000 but you have only insured them for R250,000 (50% of their value), and you suffer a loss of R100,000, the average clause means your insurer will only pay R50,000 (50% of the claim).

Underinsurance most commonly occurs when:

• Insured values have not been updated to keep pace with inflation or rising replacement costs
• New items have been acquired without updating the policy
• Building sums insured are based on market value rather than replacement (rebuild) cost

At Ambiton, we conduct regular policy reviews to identify and address underinsurance before a claim arises.