Guide to appealing denied insurance claims in Kenya. Learn the appeals process, how to strengthen your case, and when to seek legal help.
A denied claim doesn't mean the end of the road. You have the right to appeal insurance claim denials and many appeals are successful with proper preparation and persistence.
Understanding why claims are denied helps you prepare a stronger appeal. Here are the most common denial reasons in Kenya:
The Insurance Act (Cap 487) and IRA regulations protect your rights as a policyholder in Kenya. You have the legal right to:
Remember: Insurance companies must act in good faith. Unjustified denials can result in penalties from the IRA.
Follow this systematic approach to maximize your chances of a successful appeal:
Carefully read the denial letter. Note the specific reason, policy clauses cited, and deadline for appeal. Check your policy document to verify their interpretation.
Collect all relevant documents: medical reports, receipts, photos, police reports, witness statements, expert opinions, and any additional evidence that supports your claim.
Draft a formal appeal letter addressing each denial reason, referencing policy terms, and attaching all supporting documentation. Be professional and factual.
Submit via registered mail or hand-deliver with acknowledgment receipt. Keep copies of everything. Follow up with a phone call to confirm receipt.
If no response within 30 days, send a follow-up letter. Document all communication attempts. Request a timeline for their decision.
If appeal denied or no response after 60 days, escalate to IRA or consider legal action. Don't give up on legitimate claims.
The strength of your appeal depends on the quality of your evidence. Here's what to collect:
Pro Tip: Get an independent expert opinion if the insurer's assessment seems unfair. Independent assessors, medical second opinions, or certified valuers can strengthen your case significantly.
Your appeal letter is your most important tool. Here's a template structure that works:
[Your Details & Date]
[Insurer's Claims Department Details]
RE: APPEAL OF CLAIM DENIAL - Policy No: [Number], Claim No: [Number]
Dear Sir/Madam,
1. Introduction: State your intent to appeal the claim denial dated [date].
2. Background: Briefly describe the incident and claim submitted.
3. Reasons for Appeal: Address each denial reason point-by-point with evidence.
4. Policy Reference: Cite relevant policy clauses that support your claim.
5. Evidence Attached: List all supporting documents enclosed.
6. Request: Clearly state you're requesting reconsideration and payment.
7. Closing: Professional closing with contact details and deadline expectation.
Key Writing Tips:
If your internal appeal fails or you receive no response within 60 days, escalate to the Insurance Regulatory Authority of Kenya.
What to Include in Your IRA Complaint:
IRA typically responds within 30 days and can mediate disputes, investigate insurers, and order payment if your claim is valid.
If IRA mediation fails or for high-value claims, legal action may be necessary. Here's what you need to know:
Cost Consideration: Many insurance lawyers work on contingency (percentage of settlement) or offer free initial consultation. For claims below KSh 200,000, legal fees may exceed potential recovery, so exhaust IRA options first.
Understanding typical timelines helps you plan and know when to escalate:
Important: Don't let deadlines pass. Most policies require appeals within 30-90 days of denial. Missing deadlines can forfeit your right to appeal.
Appeals succeed more often than you might think. Here are real scenarios from Kenya:
Overall Success Rates:
Denial: Insurer denied KSh 350,000 cancer treatment claim citing pre-existing condition.
Appeal: Policyholder obtained medical records proving no symptoms or diagnosis before policy start. Got independent oncologist opinion.
Result: Full payment after IRA intervention. Claim paid within 45 days of IRA filing.
Denial: Insurer offered KSh 800,000 for total loss. Owner claimed KSh 1.2M.
Appeal: Owner got independent valuation from certified valuer, provided recent service records and market comparisons.
Result: Settled at KSh 1.05M through internal appeal. No IRA filing needed.
Denial: KSh 2M life claim denied for non-disclosure of medical history.
Appeal: Beneficiary proved deceased answered application questions truthfully with medical records. Condition developed after policy issuance.
Result: Full payment after legal action. Court ruled in favor of beneficiary.
If the claim incident occurred while the policy was active, you can appeal even if it has since lapsed. However, if premiums were unpaid at the time of the incident, the appeal is unlikely to succeed unless you have proof of payment or a grace period.
Internal appeals and IRA complaints are free. Legal representation costs vary: KSh 20,000-100,000 for lawyers, or 15-30% of settlement on contingency. Small claims court filing fee is minimal (under KSh 2,000).
No. Legitimate appeals are your legal right and should not result in premium increases or policy cancellation. If an insurer retaliates, report them to IRA immediately.
Yes. If the insurer admits partial liability, request interim payment for the undisputed portion while appealing the rest. This is common in valuation disputes.
Contact IRA's consumer education team for free guidance, or consult with an insurance advisor. In Kenya, policy terms must be clear and ambiguities are interpreted in favor of the policyholder.
Yes, absolutely. Continuing premium payments shows good faith and prevents the insurer from canceling your policy during the appeal process. It also strengthens your position.
Maximize your chances of success with these proven strategies:
Final Advice: Insurance companies count on policyholders giving up. Persistence, proper documentation, and knowing your rights are your greatest assets. Many seemingly hopeless cases succeed when appealed properly.
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