Don't agree with the result of a life insurance claim? What you can do if you have a complaint.
If you think that you're claim was unfairly dismissed, you have options. Every insurer has an internal dispute resolutions team that is ready to handle complaints from people who believe that they had a legitimate claim that was dismissed without payment. If an insurers internal dispute resolution doesn't get you to a solution, there are still other options.
Dispute resolution can be frustrating but it doesn't have to be a complicated process. This guide should help you understand the process of dispute resolution and what your options are should you still feel hard done by at the end of the process.
Steps to take to sort out life insurance disputes
It's crucial to familiarise yourself with the steps that you should take in the event of insurance disputes, as this will enable you to act more decisively and use your time wisely on the proper course of action in the event that you have a dispute that needs to be addressed. In the event of a complaint or dispute you should look at taking the following steps:
- Check your policy. Before doing anything make sure you've read through your policy to make sure you are actually covered. Check your policy, including the small print, to see whether you actually have a case or whether the insurance firm is acting in line with its terms and conditions.
- Speak to your provider. If you believe there is an issue after checking the policy, you should contact your insurer and explain your concerns and discuss what can be done to resolve the dispute. Often, a satisfactory conclusion can be reached simply by speaking to the insurer and discussing the issue.
- Put in a complaint with your insurer. If you're unhappy with the resolution after speaking with your insurer, you will need to go through your insurers dispute resolution process. This generally requires putting your complaint in writing. Your insurer will give you a timeframe of when this issue should be resolved.
- If all else fails: Australian Financial Complaints Authority. If you have gone through the dispute resolution process and you are still not satisfied with the outcome, you should contact the Australian Financial Complaints Authority (AFCA) or in the past, the Financial Ombudsman Service (FOS). Escalating your dispute may mean that you have to wait even longer for a resolution but if you have exhausted other avenues, this may be the route to take in order to get the dispute resolved once and for all.
Pre-existing medical conditions and life insurance disputes
A common cause of life insurance disputes revolves around pre-existing medical conditions. Each year, the AFCA is contacted by hundreds of cases of people following their income protection claim being rejected. The life insurance company has usually rejected the claim due to the policyholder not letting them know about a pre-existing medical condition related to their claim. These cases highlight the sheer importance of disclosing all known information to insurers before signing the contract of insurance. Many applicants will withhold details of pre-existing conditions or lifestyle habit in an attempt to save on their policy premiums. As part of the insureds duty of disclosure, it is their responsibility to state all known information regarding pre-existing medical conditions to their insurer to avoid this situation occurring.
Definition of a pre-existing medical condition
A pre-existing medical condition is commonly recognised as any condition:
- That was previously diagnosed or investigated
- Where there were symptoms that lead to the diagnosis prior to application
- Or event that lead to the claim occurring took place
- Prior to the official commencement date of the policy or the effective date of any increase of the policy sum-insured.
What are the requirements of the life insured under the duty of disclosure?
Under the insurance contract act of 1984, each applicant is required to state every matter that they know, or would be expected to know that is relevant to the insureds decision to provide cover and at what rate. Each applicant will be required to answer questions during the application regarding their health, occupation and lifestyle. It is safer to contact your insurer to discuss any matter that you are unsure about disclosing during the policy application to avoid any surprises at claim time.