Denise Gabriels, Lead Ombud of the Life Insurance Division of the NFO

Not every file that crosses the desk of the Life Insurance Division of the National Financial Ombud Scheme (NFO) ends in disappointment. Often, the NFO’s intervention flips the script - turning a declined claim into a paid one, restoring dignity, and rewriting a family's future.

Since January 2025, the Life Insurance Division has helped unlock millions of rands in claim reversals and service-related compensation - money that was once out of reach for grieving families and vulnerable policyholders. But these victories aren’t just financial.

These are the quiet wins that rarely make headlines but echo through hundreds of households where each payout carries the weight of restored trust, gratitude, emotional closure, and the quiet relief of knowing someone finally listened.

From January 2025 to date, the Life Insurance Division has recovered a total of R140 688 800 (R140,6 million) in respect of claims, including declined claims that were reversed, and compensation awarded for poor service.

NFO shines a light of hope

Denise Gabriels, Lead Ombud of the Life Insurance Division of the NFO, said: “Every day, South Africans face a barrage of troubling headlines - violence, corruption, despair. These stories weigh heavily on our national spirit. At the NFO, we don’t ignore these realities. But we also believe in shining a light on something else: stories of fairness reclaimed, dignity restored, and hope renewed.

“Our mission is to resolve financial services complaints fairly, impartially, and efficiently. We operate independently and without fear or favour, always guided by our values of excellence, integrity, passion, and vision.

“Sometimes our interventions mean that claims once declined are paid in full, delivering life-changing outcomes for families. These stories seldom make front-page news, but they are the ones that allow people to breathe easier, free from the weight of financial hardship.

“Since the beginning of this year, our interventions have resulted in millions of rands being paid back to complainants, alongside additional compensation in cases of poor service. Beyond the numbers, these outcomes carry profound personal impact.”

Misrepresentation by advisor

Gabriels cited a recent final ruling that ordered Metropolitan Life to pay a funeral claim of R20 000, which was initially declined on the grounds that the deceased did not qualify as a parent under the policy.

The case centred on a misrepresentation by a Metropolitan financial advisor, who had knowingly listed the deceased (described by the policyholder as her godfather and mother’s ex-partner) as her "father" during the policy application.

The insurer argued that the insured did not meet the definition of a parent in the policy contract and that the policyholder should have verified this upon receiving the documents.

The case was considered in a meeting of adjudicators chaired by the Lead Ombud. The adjudicators ruled that the advisor’s conduct created a legitimate expectation that the cover was provided. The panel held that insurers are bound by what is communicated at application stage when incorrect information is given by their own representatives.

Declined claim paid in full

Citing long-standing legal principles, the ruling stated that a party cannot benefit from its own error at the expense of another. As such, the original R20 000 claim, where the waiting period had expired, was upheld. Metropolitan accepted the decision and paid the benefit in full.

Gabriels said insurers are bound by representations made by their agents during the application process.

Policyholders have a reasonable expectation that the terms of a policy reflect what they were told at inception. Misrepresentation by a financial advisor can render the insurer liable, regardless of what the written contract may say.

“An insurer cannot escape liability by pointing to a policyholder’s oversight if the policy was issued based on incorrect information provided by its own representative. This ruling serves as a critical reminder to insurers of their obligations in ensuring transparent and accurate policy information and reinforces the protection of policyholders.

“On the other hand, consumers must answer questions at application stage fully and honestly. Always request and keep a copy of your policy document and read the terms and conditions carefully. Keep your beneficiary nominations up to date.

“If you have a dispute with your insurer that remains unresolved after their final response, you may escalate the matter to the NFO for free, independent assistance,” Gabriels added.