Why do insurers take too long to settle or payout claims?
Well, this question has become so common among many policy holders.
And while delays can be caused by several factors including long investigations, disputes or mere stall tactics by insurance companies, this post is here to remind and explain to you your rights to information and how you can file for dispute when need arises.
The fact sheet below is only applicable to general insurance claims which include accidents and sickness, motor vehicle insurance, home and contents insurance, travel insurance, pets insurance as well as consumer credit policies.
Mark from Landsborough has a general home insurance policy that provides cover for her family home on the Sunshine Coast. He lodged a claim when he noticed damage from the hail storm in Landsborough this year. Mark has been contacting his insurance company day after day for the last couple of weeks, but the insurer has done nothing to date. When he finally gets through to his insurer they only promise to get back to him but time goes on and he hasn’t heard from them. Mark has provided all the details and documents requested by the insurer but they’re yet to make a decision.
How Long Should Your Insurer Take To Process A Claim?
Below is a flowchart that highlights the timeframes applicable to insurance companies under the General Insurance Code of Practice starting from the time that you lodge an insurance claim with your insurer.
The General Insurance Code of Practice provides the above information as a stipulation for timeframes. Insurance companies have up to 45 days to respond or resolve a dispute or complain from the time you informed them of it. Once the 45 days elapse, you can file a complaint with AFCA.
In addition to the above requirements, below are deadlines applicable to the insurer’s process of making a decision on your claim:
Keep in mind that it doesn’t mean you will have to wait 4 or 12 months before you can lodge a complaint. It only means that your insurance company will have violated the General Insurance Code of Practice if the above deadlines are not met. When you lodge a complaint, this information should be highlighted.
Special Circumstances In This Case Include:
- Extraordinary natural disaster or catastrophe.
- Fraud or suspicion of fraud considered reasonable.
- When you fail to respond to your insurer’s reasonable requests for documents or inquiries for information.
- Challenges communicating to you due to situation beyond your insurer’s control, or
- When your request comes in late during the claims process.
Don’t hesitate to raise a complaint before the four or twelve months elapse if you feel the insurer is being unfair or unreasonable in processing your claim.
When Your Insurer Appoints An External Expert To Assess And Provide A Report About Your Claim:
Sometimes your insurance company can engage an expert and instruct them to deliver a conclusive report within a given period. If the report is not received within the timeframe, your insurer will inform you and keep you updated about the process of getting it.
You have rights to ask for a copy of reports or information that formed the basis of the decision regarding your claim.
In extraordinary circumstances, or in case a claim has been or is being investigated, your insurance company may decline to share the information though this shouldn’t be done unreasonably.
In the event that your claim is denied, you have the right to request for copies of the external expert’s reports relied upon by the insurance company to make the decision. These reports should be send to you within 10 business days from the date of your request.
What To Do When Your Insurance Claim Is In Limbo
If your insurance company has failed to make a decision within the stipulated time and there’s no communication as to why there’s a delay or whether additional information is required, then you can go ahead and file for dispute.
It’s advisable that when you feel the delay is unreasonable and are unsatisfied with your insurer’s reasons for the delay, you should first contact the insurance company before lodging a dispute.
Insurance Claim Dispute Process
It involves 2 steps:
Step 1: Internal Dispute Resolution (IDR)
This is usually the dispute handling department instituted within the insurance company. Hence, you only need to call your insurer and state that you have a complaint or dispute regarding the delay in making a decision in relation to your claim. Insurance companies are expected to comply with the timeframes stipulated in the General Insurance Code of Practice.
Insurers have to comply with time-frames in the General Insurance Code of Practice.
Contact details of insurers’ complaints department can be searched here: https://afca.org.au/make-a-complaint/findafinancialfirm/
IDR is mandated to respond within 45 days from the date you first lodged a complaint with the insurer. Once IDR makes a decision, it’s expected to issue a written decision clearly detailing reasons for their decision and specifying your rights to escalate the matter if unsatisfied with their decision.
If they fail to resolve the matter within 45 days, you have the right to lodge with the Australian Financial Complaints Authority (as below).
Step 2: Australian Financial Complaints Authority (AFCA)
AFCA is an external consumer dispute resolution scheme that is free and independent.
The online complaints form available at https://afca.org.au/make-a-complaint/ is the easiest way you can file a complaint and an email will be send to you immediately confirming your case reference number.
You also have the option of calling via phone number 1800 931 678 for further assistance.
AFCA is designed to be consumer friendly and hence you can access their services without the need of representation or legal advice (though you may consider it in case you’re unsure of your rights or just need additional backup). Notably, AFCA does not provide legal advice since they are duly independent.
If you feel your insurance company has unreasonably delayed your claim yet they had all the necessary information needed to make a decision concerning your claim, you are allowed to ask for interest once your claim is successful.
You can request for interest from the time the insurance company realistically should have made a decision.
AFCA explains the process for awarding interest in this link: https://www.afca.org.au/about-afca/rules-and-guidelines/application-of-interest/
AFCA has the discretion to award a maximum of $5,000 in non-financial loss i.e. losses such as excessive level of inconvenience as well as stress and anxiety caused by the insurance company.
Generally, AFCA is often conservative when it comes to this kind of loss, hence medical certificates or any other evidence can prove useful.
AFCA explains the process of awarding non-financial loss here https://www.afca.org.au/public/download.jsp?id=7229