When a valid Insurance claim is relatively simple and all relevant information is provided, it can be settled and closed quickly. Unfortunately, not all claims are straightforward, and both the broker and insurer are limited to the information received from the insured.
When a claim is declined, the insured can appeal the decision via the insurer’s claim dispute resolution process. This is an opportunity for the Insurer to reconsider the claim with any additional information.
This article discusses the claims dispute process, and some suggestions to help secure a more favourable outcome.
So, you have received a letter declining the claim – what now?
Once a formal decline letter has been issued, you (the insured) can contact your insurer to appeal their decision by following the Dispute Resolution process below:
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- Internal dispute resolution – The insurer will complete an internal review of the claim. You can supply additional information you believe has been overlooked or misunderstood
- External dispute resolution – If your insurer maintains its decision after its Internal Review, you can pursue an External Review through the Australian Financial Complaints Authority (AFCA)
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Note: a formal decline letter should include the dispute resolution process and the contact details to pursue a dispute resolution.
If you want to dispute an Insurer’s decision…
Below are some steps you can take to dispute an insurer’s decision:
1. Understand why the claim has been declined
When an Insurer issues a Formal Decline letter, the letter should detail what information has been considered and clearly explain the Insurer’s reason for reaching this decision.
Claims can be declined for a range of reasons including claims being made outside the Insurer’s policy period, a claim being submitted for an uninsured item (e.g., contents items being claimed under a building policy), or insufficient information being provided to support a claim.
Once the reason for the Insurer’s decision to decline the claim is understood, it should help to clarify the appropriate next steps. In some cases, the claim may simply need to be resubmitted to the correct Insurer.
2. Seek a second expert opinion
For property insurance claims, insurers have a panel of repairers or assessors they appoint to provide an opinion on the claim. In the past, we have seen situations where a claimant believes the Insurer’s appointed repairer is biased.
If you disagree with the appointed repairer’s opinion, we encourage you to appoint your own independent repairer for a second opinion on the claimed damage. If your repairer’s feedback supports your claim, we recommend you submit this to the Insurer so they can reconsider your claim. If the Insurer overturns their decision, we suggest you submit the report fee invoice to the Insurer for reimbursement.
3. Clearly explain why you disagree with the Insurer’s decision
In the past, I have seen dispute requests being made without claimants supplying any additional information for consideration. The dispute resolution process is an opportunity to clearly explain the reason you disagree with the decision or to clarify any information you believe has been misunderstood.
For Property Insurance claims, the lot owner will be most familiar with the damage that has occurred at their property, whereas the Insurer is limited to the Information supplied to them. Be sure to carefully consider any information you might have that could be submitted to support your claim.
If you are unsure about how to proceed, feel free to reach out to your Honan Broker for further advice.
Claims Executive – Risksmart
clarissa.reyden@risksmartclaims.com.au