Categories
Insurance

Home Insurance Claim – Making a Complaint

As an Insurance Consumer, you have a number of rights:

– That your insurance product performs as sold to you

– You receive fair and prompt treatment

– Your claim is not unreasonably rejected

It is not uncommon throughout the life of a household claim for a claimant to experience some difficulties relating to the above points with either the Insurer or their appointed Loss Adjuster and in the event that any of these difficulties arise, you have a right to consider a formal complaint.

Before escalating to the Financial Ombudsman Service (FOS) however, you should initially raise the complaint via telephone or in writing to the Loss Adjuster / Insurer to give them an opportunity to review. They will then have 2 options:

1. Resolve your complaint within 24 hours of receipt

2. If unable to resolve your complaint within 24 hours of receipt, they are required under FSA regulation to record and deal with the complaint formally (these recorded complaints are required to be declared to the Financial Services authority who monitor complaints levels and Insurers are therefore keen to prevent these as much as possible).

If you are unable to easily resolve the complaint via telephone or email etc or if the complaint is of a substantial nature, it is recommended that you issue your complaint in writing and if possible, it is more effective if you can locate the details of the Insurers Chief Executive name and location as any complaints addressed to them are generally treated as higher profile.

In the event that your complaint is formally logged, it will normally be dealt with by a Customer Relations team which reside within most key Insurer firms. You will receive a written acknowledgement of the complaint and this will also outline their internal process which will normally require a full review of your claim and a formal response to any points raised.

An effective letter of complaint should include:

Your policy information-

-Full details of your issues (including dates, times, who dealing with etc – this is where keeping a detailed claim log from the start of your claim can prove very valuable).

-It is useful to cite some breaches under FSA regulation if applicable ie: for unwarranted delays, a breach of treating customers fairly principle – refer to ‘Your Consumer Rights’ factsheet for more detail.

-Detail the detriment that the poor service or claims decision has had on you or your family (such as health risks, stress, inconvenience, loss of earnings etc as appropriate to your own situation).

-If you feel strongly about how you have been treated or how your claim has been handled, make it clear within your letter that if you do not get a satisfactory outcome to your complaint, you will be required to escalate the complaint to the Financial Ombudsman.

Insurers have an 8 week deadline to fully deal and respond to your complaint (they can request an extension from the FSA however, these are not common), however, the majority will be dealt with much sooner than this, especially if less complex issues are raised. Insurers final response should detail:

-A summary of your complaint

-A summary of the outcome of their investigations

-If they agree that they are at fault, or partly at fault

-Detail on how they propose to settle your complaint (ie: decisions, outline of any compensation if appropriate etc).

-Timescales on what they are proposing to do and for your acceptance

-A leaflet with the Financial Ombudsman contact details including the procedure for escalation together with confirmation that you have a 6 month timeframe in which to pursue

Following the final response to your complaint, if you are still not happy with the outcome, you are then entitled to refer your complaint to the Financial Ombudsman Service (FOS) which is a free service for Consumers (paid for by charges to UK Insurers).

It costs an Insurer a £500 fee for each and every case that is referred to the Ombudsman and in addition, the complaint is recorded as a statistic against the Insurer which can have an adverse affects and publicity on an Insurer if their complaints ratio is high. This is worth noting as the majority of Insurers will exhaust all avenues in trying to resolve the complaint to prevent it being escalated to FOS which on occasions will result in them offering financial compensation, paying some items of claim under dispute even in the event that it is not fully evidenced that it’s covered etc. to avoid this.

THE OMBUDSMAN COMPLAINT

Once a complaint has been referred through to FOS, they will review:-

-The nature of your complaint and whether the issues raised have caused you any financial loss, distress or inconvenience to ensure that you have had a valid reason for complaining.

-Insurers previous involvement and complaint response to establish if this was actually fair and reasonable.

-As to whether the complaint has any reasonable success prospects.

If the complaint review is to proceed, they will then proceed to review the claims paperwork and will also provide the Insurer with an opportunity to make any representations in support of their own decisions and having obtained all sides of the story and facts surrounding the case.

Insurers will tend to apply contract terms more strictly on a Consumer, however, the FOS will tend to review a number of factors when considering the overall decision – the policy wording, the decisions made and why, good industry practice and whether an Insurer decision has been fair to a customer. As such, the FOS tends to be perceived as more lenient in a number of cases than the Insurance company claims department / adjusters would be and many cases are ruled in favour of the Consumer. The Customer relations departments who deal with complaints within the insurance companies would normally be trained to take a similar approach to the FOS to enable them to resolve a higher number of complaints themselves without them being referred.

Following completion of the investigations, they will make a final determination on the complaint which will be:

– They will reject the complaint (it will be in favour of the Insurers)

– They will uphold the complaint (it will be in favour of you)

– They will partially uphold and reject certain aspects of the complaint

Formal written confirmation of the decision will be provided to both the Insurer and to you and this will outline the decision and the reason it has been made. In the event that your complaint is successful or partially successful, they will outline the remedy required by Insurers and if you accept, both you and the Insurer are legally bound to accept. These may include:

– Compensation payable to you from the Insurer

– An apology to you from the Insurer

– Payment for part or all of your claim where appropriate

If a compensation payment is ordered as a result of the Insurer’s behaviour, there will be a number of things taken into consideration to establish a fair amount to be paid including what your financial loss equates to together with consideration for stress & inconvenience caused to you and occasionally, if there has been any damage to your reputation.

WHAT IF I DISAGREE WITH THE OMBUDSMAN DECISION?

If you are still not satisfied with the outcome and do not accept the decision / remedy within the specified timeframe, the decision is therefore not binding on any party and if you wish to pursue the matter through the courts, you are legally entitled to (please note however that this can be a costly process for you and it is not recommended if there are not any further grounds to continue disputing).