Dotsure claims ilnness but repudiates claims that the accident that caused the trauma in first place

: FORMAL DISPUTE AND APPEAL AGAINST REPUDIATION OF CLAIM

Policy / Claim ***-00007 Pet’s Name: Biscuit Policyholder Name: M. van der Merwe Contact Number: *** Date of Incident: Saturday, [Insert Date, e.g., 22 August 2026] Claim Amount: R2,600.00

To: Dotsure Claims Department & Senior Claims Management (***) CC: Legal & Dispute Resolution (***)

1. NOTICE OF FORMAL APPEAL I am writing to formally dispute the repudiation of my accident claim (***-00007) submitted for emergency veterinary treatment rendered to my dog, Biscuit.

Dotsure rejected this claim on the basis that the ICD-10 diagnostic coding submitted by the veterinary practice designates an "illness" rather than an "accident." I place on record that this rejection is factually incorrect and legally unsustainable under South African short-term insurance law. I hereby request an immediate review by senior claims management.

2. FACTUAL BACKGROUND Inception of Risk: On Saturday afternoon, upon returning home from an outing, I discovered that Biscuit had suffered an acute, sudden physical injury resulting in severe paraphimosis (trapped penile prolapse). Emergency Response: Biscuit was in acute distress. Aftermanual assistance failed and the problem persisted, he was taken to the veterinary clinic for emergency surgical reduction, anesthesia, and medical care. Absence of Prior History: This policy was taken out months ago, and this is Biscuit's first claim. There was zero pre-existing medical history or leading biological illness prior to this event. 3. LEGAL GROUNDS & STATUTORY COMPLIANCE 3.1. The Legal Principle of Proximate Cause Under South African short-term insurance common law (Rule of Proximate Cause), liability is determined by the dominant, direct, and originating cause of the loss—not by secondary clinical complications.

The proximate cause was a sudden, external, unforeseen physical event occurring abruptly on Saturday. The presence of localized inflammation or contamination caused by Biscuit instinctively licking the trapped tissue is a secondary consequence of the acute mechanical entrapment. It does not alter the fundamental nature of the primary physical trauma into a chronic or pre-existing "illness." 3.2. Misapplication of Administrative ICD-10 Codes & Legal Precedents ICD-10 clinical codes are administrative categorizations designed for human medical billing, not definitive determinations of insurance liability. Over-relying on an automated ICD-10 code classification to reject an acute trauma claim ignores the actual clinical mechanics of the injury.

Furthermore, I direct Dotsure’s attention to established legal principles and case law:

National Financial Ombudsman (NFO) Precedents: The Ombudsman consistently rules against insurers who rely on automated ICD-10 diagnostic codes to auto-reject claims when clinical notes prove acute trauma. Administrative coding cannot override clinical evidence demonstrating acute mechanical trauma, nor can secondary inflammation negate an originating accidental cause. Santam Limited v Webb (2002) (SCA): The Supreme Court of Appeal established that the legal onus of proof rests entirely on the insurer when relying on an exclusion or classification. If Dotsure claims this condition is an "illness," Dotsure bears the onus of medically proving that no external or mechanical trauma caused the condition. King Price Insurance Co Ltd v Concise Consulting Services (2021) (SCA): The SCA reaffirmed that insurers cannot apply administrative or procedural assumptions to deny coverage where the factual evidence shows an acute event occurred in good faith. 3.3. Financial Sector Conduct Authority (FSCA) Policyholder Protection Rules (PPRs) Under the Short-term Insurance Act 53 of 1998 and the FSCA PPRs (Rule 17 - Claims Management):

Insurers are legally required to treat policyholders fairly, conduct reasonable investigations, and evaluate claims based on factual merit rather than rigid automated coding parameters. Under the rule of contra proferentem, any ambiguity in contract terminology or arbitrary classification must be interpreted in favor of the policyholder. 4. DEMANDED REMEDY & NEXT STEPS Biscuit’s condition was an acute, sudden physical emergency covered under the scope of my Accident Policy. I hereby request that Dotsure:

Re-open and re-evaluate this claim in light of the proximate cause of the injury and the legal precedents cited. Approve indemnification for the full claim amount and benefits of accidental coverage of R2,600.00 (or the maximum applicable limit under accident cover). Please provide the written outcome of this formal internal review within 7 business days. Should Dotsure maintain its repudiation, please provide a formal Letter of Repudiation detailing the exact policy exclusions re**** upon so that I may immediately escalate this matter to the National Financial Ombudsman Scheme (NFO).

Yours sincerely,

M. van der Merwe Phone: ***