Our Brisbane Lawyers have significant experience dealing with insurance companies and disputes with insurers. Robert Aitken has worked for many different insurance companies during his years as a solicitor. He has also held positions such as General Counsel and Company Secretary for multinational insurance companies and understands their business practices, what drives them and including importantly how they deal with claims and those who have policies with them.
Claims are dealt with on a commercial basis. While the large majority of claims are paid by insurance companies, disputes can arise and claims can be rejected for a variety of reasons. If that happens, you should first look at the Product Disclosure Statement you were given by the company to see what part of it they are relying on to reject your claim, but also, this document will set out the procedures you should take to make a complaint if you are not happy with the decision. Those procedures will usually have processes as set out below.
Most disputes with insurance companies can be dealt with first through their own complaint procedures. It is a condition of most licences insurers hold that they provide dispute procedures and are members of an external dispute resolution process. Generally, the process will include making a complaint to a claims manager. The company should respond to that complaint within a short period of time, usually around 5 days. If an insured is still unhappy with the result, then the matter can be escalated to the internal dispute resolution (IDR) processes within the company.
Those involved in the IDR should be managers who have some independence from your claim and also from that particular claim manager. Again, the response to you should be a short period of time around 15 business days unless further information is needed.
Finally, if you are still aggrieved by the decision, you can make an application for review of that decision to the external dispute resolution body. That body is independent from the insurance company and usually will be the Financial Ombudsman Service (FOS) for general and life insurance matters. You need to make the application within 3 months of the decision by the insurance company otherwise you could lose your rights, so you shouldn’t delay in obtaining advice. For further information, see their website.
What is beneficial about all the above dispute procedures for you as an insured, is that the above procedures are free to you and their decisions are binding on the insurance company but not on you (unless you agree to be bound by their decision). So if you are still not happy, then you can still take your matter to Court. Of course, you can take your matter to court straight away without going through these procedures. But usually they are quick and effective and can provide positive results.
There are limitations on the complaints process outlined above. For example, the FOS doesn’t usually deal with commercial matters and is more designed for individual consumers rather than businesses and looks at insurance like motor vehicle disputes, home and contents, consumer credit, travel insurance and the like. It also doesn’t generally have jurisdiction over claims that are larger than $280,000. What that means to you is not that you don’t have rights, but simply that you may need to take the matter to Court earlier if you are not successful through the internal dispute processes with the company.
In our experience, a lot of claims can be resolved through the internal and external dispute resolution processes. If these provide the results you want, you can still have a Court determine your matter.