I am writing to respectfully but strongly challenge the outcome of my wife's claim review with FNB Law on Call, which was rejected on the grounds that her application does not present any further material arguments to cover the matter and that she lacks reasonable prospects of success. This determination appears to be based on an overly restrictive interpretation of the policy terms, which is not supported by the relevant case law or regulatory framework. I firmly believe that this decision is unreasonable, unjust, and contrary to the principles of fairness and good faith that underpin the insurance contract.As the policyholder, I have carefully reviewed the Terms and Conditions of my policy, and I am convinced that my wife's claim falls within the scope of coverage. Furthermore, I believe that FNB Law on Call has failed to properly assess her case and has not provided adequate reasons for rejecting her claim. I believe that FNB Law On Call failed to adequately investigate my wife's claim and did not provide her with the level of representation that she deserved. The claim review outcome letter dated 17/12/2024 states that my wife's application does not present any further material arguments to cover the matter. However, she had provided strong reasons to support her claim, which were not properly considered by FNB Law on Call. I strongly disagree with the decision and believe that it is based on a flawed assessment of the merits of my wife's case. The letter states that she lacks reasonable prospects of success, but I believe that this assessment is not supported by the evidence and is contrary to the principles of fairness and good faith.I am confident that a fair and impartial review of her case would result in a different outcome. I respectfully request that you review my wife's case and consider the following:• Background information, as to why FNB Law on Call's decision to decline claim coverage for my wife's dismissal on October 31, 2024. The reason provided for the dismissal was misconduct, specifically incorrect invoicing and failure to comply with lawful instructions, which allegedly occurred on September 30, 2024.• Furthermore, I would like to bring to your attention the unusual circumstances surrounding the disciplinary proceedings. On November 6, 2024, my wife requested recordings of the proceedings, which is a reasonable request. However, the employer summoned her to the office shortly after, with the shop steward present, without her knowledge or consent. This raises concerns about the employer's handling of the disciplinary proceedings and potential unfair labor practices. In light of these circumstances, I believe that the insurer's decision to decline coverage is unreasonable and unjust. I request that you reconsider the decision and take into account the potential unfair labor practices and the employer's actions, which may have contributed to my wife's dismissal.• I understand that Insurer's decision is based on the Terms and Conditions, specifically section 6, Exclusions (when will you not be covered and any matter ruled out by their expert opinion?). Nevertheless, I would appreciate a more detailed explanation of how my case falls under this exclusion. Because on their first reply dated 2/12/2024, they said after reviewing her documents, they have considered the merits of her case. As it appears that she has valid arguments regarding the substantive aspect of her dismissal, the fact that she signed the settlement agreement, accepted one month's salary, and waived her right to refer the matter to any forum diminishes the prospects of success for her claim due to caveat subscriptor. The insurer seems to overlook that under these circumstances, the Iustus Error Doctrine is a corrective measure when dealing with the dissensus of a contract. My wife should not be held bound to an agreement she consented to under duress and coercion. The insurer needed to ascertain if the signatory understood all the contractual terms and whether the signatory was only required to understand the contract reasonably. But they failed to reach out to her.• The fairness and reasonableness of FNB Law on Call's decision-making process• The delayed policy reinstatement by FNB Law On Call staff. On 28th and 29th October 2024, I interacted with FNB Law On Call desk consultants both through chats and telephonically to request policy reinstatement and to start debit on the 25/11/2024 and change banking from Capitec to FNB account, which was confirmed. However, to my surprise, they continued to debit my Capitec account on the 1/11/2024, a date that was not requested, causing the policy to lapse again. On the 2/11/2024, I interacted with FNB Law On Call consultants again to request policy reinstatement, but I could not be assisted. They promised to resolve the matter from the 2/11/2024 but it was not done and have been interacting with them until the 6/11/2024 but still failed to reinstate the policy. Later that day, on the 6/11/2024, my wife received a call to meet with her employer on the 8/11/2024. Unfortunately, on the 7/11/2024, I could not reach out to FNB Law On Call. However, on the 08/11/2024, I interacted with FNB Law On Call consultants again to request that they hear my urgent plea to attend to this matter urgently. The lady consultant assisted me stated that the request for reinstatement had been escalated and would be sorted soon but it didn't and she concluded saying she will callback to provide feedback, but it was not resolved that day. Instead, it occurred on 11/11/2024, on Monday morning I followed up thus when policy reinstatement confirmed by the consultant attended to my request after multiple requests from me dating from the 2/11/2024. This delay had a significant impact on my wife's ability to receive timely advice from FNB Law on Call lawyers and could have been avoided by the Insurer's consultants, their inability to resolve the matter timely in turn affected my wife's ability to navigate the dismissal process.• My wife became emotionally distressed upon hearing that her claim would not be covered by FNB Law on Call, which has had a devastating impact on our family, particularly our children. The loss of income has affected her ability to pay bills, which has affected our children's schooling. Insurer's decision to decline coverage will have long-term consequences for our children's education and future prospects.I am writing to express my strongest objections to the decision by FNB Law on Call to decline coverage for my wife's dismissal claim. Their expert opinion is based on a narrow and technical interpretation of the policy terms, disregarding the broader context. Furthermore, I argue that this decision breaches the principles of fairness and good faith outlined in the Policyholder Protection Rules (PPR) published by the Financial Services Board. According to the PPR, insurers are required to act with utmost good faith in the handling of claims. Specifically, Rule 2.1 of the PPR requires insurers to treat policyholders fairly and without bias, while Rule 2.2 demands clear and transparent reasons for claim rejections. As a policyholder, I am compelled to bring to your attention the insurer's failure to comply with the Policyholder Protection Rules (PPR) and Section 54(1) of the Short-term Insurance Act 53 of 1998. In terms of Section 54(1) of the Short-Term Insurance Act 53 of 1998, FNB Law on Call is required to act with utmost good faith in handling my wife's claim. This includes providing clear and transparent reasons for the rejection, as well as ensuring a fair and unbiased assessment of the facts. This section dictates that insurers must act with utmost good faith in the handling of claims, and that policyholders are entitled to fair and transparent treatment. I submit that FNB Law on Call's rejection, based on an unsubstantiated expert opinion, falls short of these standards. The Policyholder Protection Rules (PPR) provide a framework for protecting policyholders' rights. In _Hart v. Liberty Group Ltd._ (2011), _Mashiane v. Old Mutual Life Assurance Company (SA) Ltd._ (2013), _Mthembu v. Momentum Life Assurance Ltd._ (2015), and _Muller v. Santam Ltd._ (2015), the courts ruled in favor of policyholders, citing insurers' failures to comply with the PPR.Moreover, I believe that the insurer's decision to decline coverage is not only unfair but also unreasonable. The policy is designed to provide protection and support to policyholders in times of need. By declining coverage, the insurer is effectively abandoning my wife in her time of need, and leaving her to bear the financial and emotional costs of the dismissal alone. The insurer's expert opinion, which states that my wife's case lacks reasonable prospects of success or economic justification, is not supported by the evidence. The doctrine of caveat subscriptor dictates that the insurer's expert opinion is merely hearsay, and therefore, lacks probative value. The following CCMA cases demonstrate that employees may challenge their dismissals despite signing settlement agreements but FNB Law on Call doesn't consider this options: (_Numsa obo Members v. Atlantis Forge (Pty) Ltd._, _Moyo v. South African Revenue Service_, and _CEPPWAWU obo Mogale v. City of Tshwane Metropolitan Municipality_) demonstrate that employees may challenge their dismissals despite signing settlement agreements. These cases show that there are valid legal grounds for challenging the dismissal, and that the insurer's assertion that there is no reasonable prospect of success is overstated.Furthermore, Pursuant to Section 186(2)(a) of the Labour Relations Act 66 of 1995 (LRA), my wife is entitled to refer the dispute to the Commission for Conciliation, Mediation and Arbitration (CCMA), despite having signed the settlement agreement. The doctrine of caveat subscriptor does not preclude her from exercising this right. Furthermore, they should consider Section 157(1) of the LRA, which provides that an employee who has signed a settlement agreement may still refer a dispute to the CCMA if the agreement is found to be unfair or unreasonable.In light of these factors, I urge you to reconsider FNB Law on Call's decision to decline coverage for my wife's dismissal claim. I believe that it is essential to ensure that policyholders receive fair and reasonable treatment under the policy, and that the decision-making process is transparent, fair, and unbiased. Anything less would be a breach of the trust and confidence that policyholders place in their insurers.I would like to emphasize that my wife's case is not just about the legal technicalities, but also about the human impact of the decision. She has suffered significant emotional distress and financial loss as a result of her dismissal, and the rejection of her claim has only added to her hardship. I implore you to consider the human aspect of this case and to ensure that justice is served. I believe and respectfully request that a thorough review of my case will reveal that FNB Law on Call's decision was unreasonable and unjust. In light of the evidence and circumstances presented, I respectfully request that you take the following actions:• Overturn FNB Law on Call's decision and direct them to pay my claim in full, as I believe that my wife's claim falls within the scope of coverage under the policy.• Alternatively, order FNB Law on Call to reconsider her claim and provide a fair and impartial assessment of her entitlement to coverage, taking into account all relevant factors and evidence.• Take any other action necessary to ensure that my wife receive fair and reasonable treatment under the policy, including but not limited to, directing FNB Law on Call to provide a detailed explanation for their decision and to rectify any procedural errors or omissions that may have occurred during the claims process.I am confident that a thorough review of my wife's case will demonstrate that FNB Law on Call's decision was flawed and that she is entitled to coverage under the policy. I appreciate your attention to this matter and look forward to your response at your earliest convenience.Kind regards