Insurer Denied Your Claim?
If an insurer has declined your legitimate claim, it can be frustrating and overwhelming. However, there is no need to hit the panic button. There are steps you can take to challenge their decision and attempt to receive the compensation you are entitled to. Pre-existing damage, maintenance issues and non-insurable events are some common examples for claim denials.
Here are six steps you can take to challenge an insurer’s decision:
Step 1 – Review Your Policy
Firstly, it’s essential to review your Product Disclosure Statement (PDS) in detail to make sure you understand the terms and conditions of your coverage. A PDS is a document provided to the consumer by the insurer with all the information about the insurance agreement. The PDS can usually be found on the insurer’s website, or you can request a copy directly from them. Usually, the insurer will refer to a specific section of the PDS to justify their decision. You should review the PDS and the insurer’s reasons for declining the claim and consider whether you agree or disagree with their decision.
Step 2 – Review the Insurer’s Reasons
Check the specific reasons the insurer gave for denying your claim to see if they are valid. An insurer is required to provide certain information to you when declining a claim, including the specific aspects of your claim that they do not accept, the reasons for their decision, the right for you to ask for information that was relied on when assessing your claims and the details of the complaints process. It’s important to know if the insurer has been thorough with their reasoning and provided evidence to support their decision. Ask questions like: have they used an expert? have they gathered enough documentation and photographs to support their decision? do you think their decision is fair? This will make it easier to form your response to the insurer.
Step 3 – Gather Evidence
It’s also important to gather any documentation or evidence that supports your claim falling within the policy terms contained in your PDS, such as photographs, expert reports, or witness statements. For example, if the insurer is claiming there was pre-existing damage to a patio deck, having a photograph that was taken directly before the insurable events would be beneficial. Note that Google street view and other online resources can be a valuable source of information to dispute an insurer’s decision.
Step 4 – Formulate a Response
Once you have reviewed your PDS and collected any supporting evidence, contact the insurer, and request a written explanation of their decision to deny your claim. Also, you may want to outline why you want this written explanation. The reason being you feel it is unjust. Try to be polite and professional in your communication and provide any additional evidence you have to support your claim. In many cases, the insurer may have made a mistake or missed important information that could change their decision.
Step 5 – Make a Complaint
If you are not satisfied with the insurer’s response or explanation, you may want to consider disputing the resolution further. You can do this by simply writing to your insurer and saying that you want to complain about the decision. When writing a complaint to an insurer you should clearly outline the issues you want the insurer to respond to and the reasons supporting why you consider the decision to be incorrect. Insurers often have 30 days to respond to your complaint.
Step 6 – Make an AFCA Complaint
If the insurer does not overturn your decision after the initial complaint, the best course of action is to make a complaint to the Australian Financial Complaints Authority (AFCA). AFCA is a free and independent, external dispute resolution scheme that resolves complaints made by consumers regarding general insurance in Australia. AFCA is free for consumers. Here is the link to our AFCA complaint blog: NAVIGATING THE COMPLAINT RESOLUTION PROCESS WITH AFCA – Claims Hero.
Step 7 – Seek Professional Help
If you are at a point where you’re feeling overwhelmed by the process or you consider your insurer is being unreasonable, it might be time to seek professional help. We offer a free initial consultation and from there can help you every step of the way to overturn the insurer’s decision. Often, we can offer you a no-win no-fee arrangement where you’ll only need to pay if we successfully overturn the insurer’s decision. There are also free services available that can be found on Google, including legal aid. Particularly complex claims may also require the assistance of an insurance lawyer.
This blog post is for educational purposes only and does not consider your personal situation. It is strongly advised that you seek professional legal or financial advice before taking any action based on the information provided in this blog.