Advertisement
As South Africa marks Money Smart Week South Africa (MSWSA) 2026, consumers are being urged to understand not only what their insurance policies cover, but also what they do not cover.
The National Financial Ombud Scheme (NFO) says insurance exclusions are among the most misunderstood parts of insurance policies and can determine whether a claim is paid or rejected.
Insurance exclusions are specific circumstances under which an insurer will not pay a claim, even if the policy is active and premiums have been paid in full. These exclusions exist because insurance is designed to protect against unexpected risks rather than losses resulting from unlawful, intentional or excluded activities.
Denise Gabriels, Lead Ombud of the NFO’s Life Insurance Division, said understanding exclusions is just as important as understanding the benefits of a policy.
«”Insurance exclusions are not hidden traps. They are fundamental to how insurance works. By reading your policy carefully and asking questions, you can avoid unpleasant surprises when it matters most.”»
Criminal conduct led to rejected claim
The NFO recently reviewed a life insurance dispute in which an insurer rejected a claim after the insured died during an attempted arrest.
According to the Ombud, evidence showed that police officers were attempting to arrest the deceased when he allegedly grabbed an officer’s firearm and attempted to fire it. He was fatally shot by other officers at the scene.
The insurance policy clearly excluded claims arising directly or indirectly from criminal conduct. As there was no evidence contradicting the police’s version of events, both the insurer and the NFO concluded that the exclusion applied and the claim was lawfully declined.
The case serves as a reminder that policy wording can have a significant impact on claim outcomes.
Common insurance exclusions
Consumers should familiarise themselves with common exclusions found in many insurance policies, including:
– Claims arising from criminal or illegal activities.
– Injuries or deaths resulting from hazardous activities such as skydiving, scuba diving or mountaineering, unless specifically covered.
– Certain pre-existing medical conditions that existed before the policy started.
– Losses caused by war, terrorism or civil unrest.
– Intentional acts, including suicide or self-inflicted injuries during the exclusion period specified in the policy.
While exclusions vary between insurers and products, policyholders should always read the policy schedule and wording carefully before signing.
Who must prove an exclusion?
The NFO explains that a policyholder or beneficiary must first show that a valid insurance policy existed and that the insured event, such as death, disability or a covered illness, occurred.
If an insurer wishes to reject the claim based on an exclusion, it carries the responsibility of proving that the exclusion applies. This may involve medical records, toxicology reports, police reports, accident investigations or other supporting evidence.
If the insurer cannot prove the exclusion on a balance of probabilities, the claim should generally be paid.
Tips for consumers
As part of Money Smart Week South Africa 2026, the NFO encourages consumers to:
– Read every insurance policy carefully before accepting it.
– Ask your insurer or financial adviser to explain any terms you do not understand.
– Disclose all relevant information honestly when applying for cover.
– Keep copies of your application forms and policy documents.
– Review your insurance regularly to ensure it still meets your needs.
Understanding your insurance policy before you need to claim can help protect you and your family from unexpected financial hardship.
Consumers who have complaints or disputes about financial products and services can contact the National Financial Ombud Scheme (NFO) for assistance.
NFO Contact Details
Telephone: 0860 800 900
WhatsApp: +27 76 574 8055
Email: info@nfosa.co.za
Johannesburg – As South Africa marks Money Smart Week South Africa (MSWSA) 2026, consumers are being urged to understand not only what their insurance policies cover, but also what they do not cover.
The National Financial Ombud Scheme (NFO) says insurance exclusions are among the most misunderstood parts of insurance policies and can determine whether a claim is paid or rejected.
Insurance exclusions are specific circumstances under which an insurer will not pay a claim, even if the policy is active and premiums have been paid in full. These exclusions exist because insurance is designed to protect against unexpected risks rather than losses resulting from unlawful, intentional or excluded activities.
Denise Gabriels, Lead Ombud of the NFO’s Life Insurance Division, said understanding exclusions is just as important as understanding the benefits of a policy.
«”Insurance exclusions are not hidden traps. They are fundamental to how insurance works. By reading your policy carefully and asking questions, you can avoid unpleasant surprises when it matters most.”»
Criminal conduct led to rejected claim
The NFO recently reviewed a life insurance dispute in which an insurer rejected a claim after the insured died during an attempted arrest.
According to the Ombud, evidence showed that police officers were attempting to arrest the deceased when he allegedly grabbed an officer’s firearm and attempted to fire it. He was fatally shot by other officers at the scene.
The insurance policy clearly excluded claims arising directly or indirectly from criminal conduct. As there was no evidence contradicting the police’s version of events, both the insurer and the NFO concluded that the exclusion applied and the claim was lawfully declined.
The case serves as a reminder that policy wording can have a significant impact on claim outcomes.
Common insurance exclusions
Consumers should familiarise themselves with common exclusions found in many insurance policies, including:
– Claims arising from criminal or illegal activities.
– Injuries or deaths resulting from hazardous activities such as skydiving, scuba diving or mountaineering, unless specifically covered.
– Certain pre-existing medical conditions that existed before the policy started.
– Losses caused by war, terrorism or civil unrest.
– Intentional acts, including suicide or self-inflicted injuries during the exclusion period specified in the policy.
While exclusions vary between insurers and products, policyholders should always read the policy schedule and wording carefully before signing.
Who must prove an exclusion?
The NFO explains that a policyholder or beneficiary must first show that a valid insurance policy existed and that the insured event, such as death, disability or a covered illness, occurred.
If an insurer wishes to reject the claim based on an exclusion, it carries the responsibility of proving that the exclusion applies. This may involve medical records, toxicology reports, police reports, accident investigations or other supporting evidence.
If the insurer cannot prove the exclusion on a balance of probabilities, the claim should generally be paid.
Tips for consumers
As part of Money Smart Week South Africa 2026, the NFO encourages consumers to:
– Read every insurance policy carefully before accepting it.
– Ask your insurer or financial adviser to explain any terms you do not understand.
– Disclose all relevant information honestly when applying for cover.
– Keep copies of your application forms and policy documents.
– Review your insurance regularly to ensure it still meets your needs.
Understanding your insurance policy before you need to claim can help protect you and your family from unexpected financial hardship.
Consumers who have complaints or disputes about financial products and services can contact the National Financial Ombud Scheme (NFO) for assistance.
NFO Contact Details
Telephone: 0860 800 900
WhatsApp: +27 76 574 8055
Email: info@nfosa.co.za
