Why insurers reject claims, according to the Ombud
Most articles on this subject list reasons that sound plausible. This one uses the published record: what the National Financial Ombud found when people complained about a rejected claim. It comes with a limit worth understanding before you read the numbers, because it measures complaints rather than rejections, and those are not the same thing.
Pocket Nerd editorial · Checked 28 September 2026 · 8 min read
Read this before the numbers
This data counts complaints, not rejections. It shows why claims were turned down among people who took the matter to the Ombud.
A rejection that nobody complained about does not appear anywhere in it. So this is not a league table of how insurers behave, and it is not the definitive list of why claims fail. It is the best public evidence that exists, and that is a different claim.
Every other page on this subject states its reasons with more confidence than the evidence supports. We would rather tell you what the number actually measures.
Where the complaints come from
Two categories account for most of it, and they fail for completely different reasons.
35%
Vehicle insurance
- Accident claims70%
- Theft and hijacking8%
Shares of vehicle disputes, not of all complaints.
27%
Homeowners insurance
- Acts of nature42%
- Burst water apparatus, mostly geysers15%
Shares of homeowners disputes, not of all complaints.
The leading reasons given
In the order the Ombud reports them, most common first.
On a vehicle claim
- 1Driving under the influence, as a policy exclusion
- 2Lack of due care, also described as recklessness
Both are things you do rather than things you failed to buy. That is the pattern on motor: cover is usually in place, and something about the driving took it away. What the first one actually means.
On a home claim
- 1Gradual deterioration, lack of maintenance or wear and tear
- 2Defective design, construction or materials
A completely different pattern. These are not about behaviour, they are about the difference between something breaking suddenly and something wearing out slowly. Where that line falls on a geyser.
The one idea underneath all of it
Insurance covers sudden and unforeseen events. Almost every rejection reason above is a version of arguing that something was neither.
A roof that leaked for two years is not sudden. A geyser that corroded slowly is not unforeseen. Driving under the influence is not an accident in the sense the policy means.
Once you see that, the wording stops being arbitrary. Everything an insurer excludes is either something you could have prevented by maintenance, something you chose to do, or something that was happening gradually while you were paying for cover against sudden events.
It also tells you where to put your attention: keeping evidence that something failed suddenly is worth more than any argument you can make after the fact.
If your claim is rejected
A rejection letter is a position, not a verdict. It costs nothing to test it.
- 1
Get the reason in writing
Ask which clause of the policy they are relying on, quoted. A rejection that cannot point at a clause is worth challenging immediately.
- 2
Read that clause yourself
In your own wording document. Insurers sometimes apply an exclusion more widely than it is written, and you cannot spot that without reading it.
- 3
Use their internal process first
In writing, with your evidence. Most ombud schemes will not take a case until the company has had a fair chance to resolve it.
- 4
Then go to the Ombud
Free, independent, and worth doing. Across all non-life insurers, 16.5 in 100 complaints ended in the customer's favour.
It takes time. The Ombud reports an average of 105 working days to resolve a complaint, so this is a route for something worth waiting for. How to complain, in order.
Questions people ask
- What is the most common reason car insurance claims are rejected in South Africa?
- Among vehicle complaints that reached the National Financial Ombud, the leading reason given was driving under the influence as a policy exclusion, followed by lack of due care, sometimes described as recklessness. Note that this measures complaints rather than all rejections: a claim someone was refused and did not complain about does not appear in the data.
- Why do home insurance claims get rejected?
- The leading reasons among complaints that reached the Ombud were exclusions for gradual deterioration, lack of maintenance or wear and tear, followed by defective design, construction or materials. The common thread is that insurance covers sudden and unforeseen events, and something that failed slowly is neither.
- Can I challenge a rejected insurance claim?
- Yes, and it costs nothing. Ask for the reason in writing including the clause relied on, read that clause in your own policy wording, use the insurer's internal complaints process first, then take it to the National Financial Ombud. Across all non-life insurers, 16.5 in 100 complaints ended in the customer's favour.
- How long does an Ombud complaint take?
- The Ombud reports an average of 105 working days to resolve a complaint. It is free, but it is not fast, so it suits a dispute worth waiting for rather than a small one.
Now go and check what you are paying
Knowing how the cover works is most of it. The rest is not overpaying for it. You choose which insurers get your details, and nobody else does.
Where this comes from
Complaint volumes, categories and rejection reasons: COVER magazine, reporting the National Financial Ombud 2025 annual report, 2025. Checked 28 September 2026. This is reporting on the annual report rather than the report itself, and it is labelled that way deliberately.
The overall resolved ratio of 16.5 in 100 is from the National Financial Ombud Scheme, Annual Report 2025.