An accident insurance claim can stall for reasons that have little to do with the accident. The insurer may dispute cover, fault, the extent of injury or the repair cost, or it may simply take time to decide. The useful first step is not a demand for payment but a clear identification of the point in dispute and the policy term said to support it. This guide sets out a practical sequence for a policyholder or an adviser managing the disagreement in Kenya.
Identify the exact point of disagreement
Read the insurer’s letter or email and separate the decision from the reasons. A decline may rely on an exclusion, an alleged breach of a condition, non-disclosure, late notice, a dispute about who was driving, a causation argument or a valuation. A reduced offer may accept cover but dispute quantum. A delay may be an information request that was never answered. Each problem needs a different response.
Create a one-page summary: policy number, date of loss, claim reference, decision, the clause or issue relied on, the documents the insurer says are missing and the outcome sought. This summary keeps correspondence focused and becomes the agenda for a complaint or a meeting.
Ask for the insurer’s position in writing
Write to the claims handler and ask for a written decision. If cover is declined or the offer is reduced, ask the insurer to identify the policy clause, exclusion or condition, the facts relied on and the calculation used. Ask what evidence would change the position. Keep the request short and neutral.
Assemble the claim file in date order: policy schedule and wording, proposal information, claim form, police or incident report, medical reports and receipts, repair estimates, photographs, assessor reports, premium records and all correspondence. Send copies and keep the originals. Do not alter documents or add information that cannot be supported. A claim record that changes without explanation weakens the policyholder’s position.
Check the policy and the facts before escalating
Coverage: does the event fall within the insuring clause? Is an exclusion engaged, and is its wording clear? Notice and cooperation: was the claim notified as required, and has the insurer identified what is still missing? Liability and causation: is fault, the identity of the driver or the cause of the injury disputed? Value: is the disagreement about repair method, medical evidence, market value, excess, contribution or betterment? Procedure: does the policy require arbitration, expert determination or mediation before proceedings?
Check the wording against the insurer’s reasons. A general statement that the claim is “not covered” is not a reasoned decision, but a clearly worded exclusion may be decisive even where the outcome is harsh. The facts must be tested against the wording, not against what the policyholder assumed was covered.
| Dispute | What to check | Useful evidence |
|---|---|---|
| Coverage denial | Insuring clause, exclusions, definitions | Policy, schedule, endorsements, proposal |
| Late notice | Notice clause, dates, channel used | Correspondence, call logs, broker emails |
| Liability | Police report, witness accounts, vehicle records | Abstract, statements, photographs |
| Quantum | Assessor reports, quotations, medical evidence | Invoices, second opinion, market data |
| Delay | Information requests and complaint route | Complete correspondence log |
Use the insurer’s complaint process
Ask the insurer to treat the matter as a formal complaint. State the policy number, date of loss, decision disputed, documents enclosed and the outcome sought. Ask for a response in writing and keep the reference. This creates a record and may resolve an information or calculation problem without a dispute.
A settlement offer should be read as a legal document. Check whether it covers all heads of loss, whether it is full and final, whether it releases future claims and whether payment is conditional. Do not sign a discharge on the spot. If the offer is unclear, ask for the calculation and for the clause on which it is based.
Consider a complaint to the Insurance Regulatory Authority
The Insurance Regulatory Authority supervises insurers and intermediaries and publishes a complaint process for customers. A regulatory complaint can be useful where the issue is delay, handling or a refusal to explain a decision. It is not a court action, it does not decide entitlement in the same way as a court, and it does not stop time running. Check the Authority’s current requirements and the documents it asks for before filing.
The Insurance Act provides a complaint route to the Commissioner. The current procedure and any time limits should be confirmed with the Authority or an advocate, because they can change. A regulatory complaint and a civil claim can run in parallel, but they serve different purposes and should be coordinated.
Choose advice, mediation or court with care
Mediation, a regulatory complaint, negotiation and court proceedings are different tools. Mediation can suit a quantum dispute where the parties want to preserve a commercial relationship. A regulatory complaint can address handling. Court may be needed where cover is denied, a declaration is sought or payment is refused. The choice depends on the policy, the amount, the evidence, the limitation position and the prospects of recovery.
Get advice before issuing proceedings or signing a settlement. A claim that is poorly framed can be expensive to correct, and a release may end rights that the policyholder did not intend to give up. If the insurer has appointed an assessor or investigator, cooperate factually but keep a record of what was provided and when.
Keep the tone of correspondence factual. Allegations of bad faith or fraud should not be made unless they can be supported, because they change the character of the dispute and may expose the policyholder to risk. A clear chronology and a precise question usually achieve more than a long complaint.
Primary sources
- Insurance Act (Cap 487), Kenya Law.
- Insurance Regulatory Authority of Kenya, including its published complaint process.
- Kenya Law, for the current text of the Act and subsidiary legislation.
This article is general information, not legal advice.