Did you know that 10 percent of all insurance claims are unfairly denied but less than 1 percent of people making insurance claims even question their insurer when their claim is denied? The majorities of policyholders who do contest their cases either win their cases or improve their settlements.
The insurance company may have interpreted a clause in your policy differently from the way you understand it. Remember, respect your sense of fairness and what you expect the policy to cover. If the ruling doesn’t sound fair, there’s a good chance that it isn’t.
The agent from whom you purchased your insurance has a duty to make sure the coverage protects your interests.
If your insurance agent or claims administrator doesn’t resolve the problem within 30 days, telephone the insurance company yourself. Be polite but persistent, and keep going up the corporate ladder. Be sure to make a record of all phone calls, including the names and positions of everyone with whom you speak. Save your phone bills that list the calls. Follow up each call with a brief letter stating your understanding of the conservations, and requesting a response within 30 days.
If you are still having problems and not much has been accomplished then they are other dispute resolution mechanisms that you can use. Enlist outside help.
If necessary, add pressure from:
Alternative dispute resolution: Alternative Dispute Resolution ("ADR") refers to any means of settling disputes outside of the courtroom. ADR typically includes arbitration, mediation, early neutral evaluation, and conciliation. As burgeoning court queues, rising costs of litigation, and time delays continue to plague litigants, more states have begun experimenting with ADR programs. Some of these programs are voluntary; others are mandatory. The two most common forms of ADR are arbitration and mediation. Arbitration is a simplified version of a trial involving no discovery and simplified rules of evidence. Either both sides agree on one arbitrator, or each side selects one arbitrator and the two arbitrators elect the third to comprise a panel. Arbitration hearings usually last only a few hours and the opinions are not public record. Arbitration has long been used in labor, construction, and securities regulation, but is now gaining popularity in other business disputes.
Types of alternative dispute resolution procedures
There are different ways of resolving disputes without going to court. These include:
- Expert evaluation
Areas in which ADR can be used:
- Commercial disputes
- Family Law disputes
- Neighbourhood disputes
- Discrimination complaints
- Health service complaints
- Work related complaints
Advantages of dispute resolution – The big advantage of these schemes is that they are free, and you do not have to pay the costs of the insurer if you lose your case. If you go to court you will generally have to pay if you lose. You do not need a lawyer to use the schemes, but it is a good idea to get legal advice if the claim involves a large sum of money. Remember, you are still entitled to take legal action if you lose the case under the scheme.
Savings in legal costs and time
- Parties can dispense with many of the preliminary steps usually required for a court hearing.
- Parties can identify the issues quickly and concisely.
- In contrast to court hearings, arbitration and mediation are conducted in private and the decisions are confidential.
- Neither the reason for a dispute nor the basis upon which it is resolved need be made public.
- Confidentiality is the most significant advantage to parties using ADR.
- An ADR process can occur at relatively short notice and at a time convenient to the parties.
Flexibility of process
- Procedures can be tailored to suit the dispute and the parties can exercise more control over the process.
- Formal litigation in court is governed by procedural rules - certain steps must be taken and the rules of evidence apply. In ADR procedures are usually less formal.
Preservation of relationship and lack of animosity
- Parties can raise relevant issues to be resolved without complying with those formal procedures, which can apply in adversarial court hearings.
- Both parties can operate within the relationship they have with the other party and minimise any negative impact once the dispute is settled.
Suitability for multi-party disputes
- ADR processes give all parties the opportunity to be heard on all relevant issues, thereby avoiding the expense associated with multi-party litigation and the need for separate claims.
More creative solutions
- ADR processes can offer more creative solutions to a dispute where ongoing relationships exist and healthy relationships need to be preserved.
- For the most part, the courts can only make orders requiring one party to pay another.
- In an ADR process, the parties can find more unique solutions that better suit their particular situation.
- General insurance disputes (IEC) - Insurance Enquiries and Complaints (IEC) hears disputes about the refusal to pay a claim concerning these types of general insurance:
- home insurance
- motor vehicle insurance (not compulsory third party insurance)
- sickness and accident insurance
- consumer credit insurance
- travel insurance
- Some types of small business, domestic and other insurance.
Common Types of ADR
- Mediation involves a qualified mediator acting as an impartial third party.
- The mediator assists the parties to resolve their differences.
- The mediator does not impose solutions.
- The parties ultimately come up with their own solutions to settle the dispute.
- Even if all of the aspects of a dispute are not settled, mediation can assist parties to agree on some issues and narrow down the issues they do not agree upon.
- This limits the issues that may subsequently go to Court.
- Parties to a dispute present arguments and evidence to an arbitrator.
- The arbitrator then makes a determination, similar to a judge.
- Parties to a dispute endeavour to reach an agreement using the assistance of a conciliator.
- The conciliator may advise on the content of the dispute or the outcome of its resolution, but does not make a determination or ruling.
- The conciliator can make suggestions for terms of settlement, give expert advice on likely settlement terms, and actively encourage the participants to reach an agreement.
- Negotiations take place in many different forms.
- They can occur with or without the aid of a third party who may be a solicitor.
- Parties to a dispute can use representatives (for example, lawyers or agents) to identify the issues to be negotiated, develop options, consider alternatives and endeavour to negotiate an agreement.
- Representatives may have authority to reach agreements on behalf of their client.
- The process may involve the assistance of a facilitator who can advise on the process to use but can’t rule on what content is discussed or make any binding decision.
- A mediator, chosen on the basis of their expert knowledge, investigates the dispute.
- The mediator provides advice on the facts and suggests possible and desirable outcomes and the means to achieve these.
- The parties’ present arguments and evidence to a mediator who provides advice on the facts of the dispute.
- The mediator can advise on possible, probable and desirable outcomes and the means to achieve these.
It is possible for the insurer to consent to having other types of insurance disputes heard by the IEC.
Certain conditions that must be satisfied: Before you can seek the intervention of the IEC because your claim has been rejected you must have first sought an internal review from the insurer. You should get a "final decision" from the insurer. This is a letter that tells you the result of the internal review you have requested. You then have three months to go to the IEC.
IEC decision making: There will be an investigation into the complaint. This is the opportunity for the dispute to be settled or conciliated. If the disputed is not resolved the dispute will proceed to a hearing, which will decide if the claim should be paid or not. If the decision is not to order the payment of the claim, you can still go to court.
Life insurance - Financial Institutions Complaint Service (FICS)
The Financial Institutions Complaint Service can hear disputes about life insurance, including certain income protection policies.
Before you can seek the intervention of the IEC because your claim has been rejected you must have first get a review from the insurer.
FICS decision making -
There will be an investigation into the complaint. This is the opportunity for the dispute to be settled or conciliated. If the dispute is not resolved it will proceed to a hearing, which will decide if the claim should be paid or not. If the decision is not to order the payment of the claim, you can still go to court.
Brokers - Insurance Brokers Dispute Facility (IBDF)
The IBDF hears disputes between consumers and insurance brokers. Brokers must be members of the scheme in order to bring a dispute to the IBDF. There are strict restrictions that apply to this scheme unless the broker agrees to have the dispute heard.
You might have a complaint if, for example, your claim is rejected because your broker failed to pass on information to the insurance company or misunderstood your needs.
There are limits to the matters IBDF can hear. It can only hear disputes:
- up to $10,000 for general insurance matters (unless the broker agrees to IBDF hearing the matter)
- up to $50,000 for life insurance matters
- That relate to the broker's acts after they joined the scheme.
Complain in writing:
This includes your name, address, policy number, and doctor's name, along with a description of what wasn't covered and why it should have been. A letter from your doctor backing up your case can definetly be helpful. Check with your plan to find out what information is required for a written appeal and where it should be sent. Get the names of people in charge of patient complaints and appeals, and address your letters (or, if appropriate, emails) directly to them. Save copies of all your correspondence. If you don't receive a response within a month or two, call and ask when you can expect one.
If you are writing on behalf of someone else, include a note signed by that person, authorizing you to act for him or her. When it is not possible to obtain an authorization, explain the circumstances in writing.
Upon receipt of your unresolved complaint, an officer will be assigned to handle your case. You will be advised about the process and what to expect. All unresolved complaints will be reviewed and a response provided.
Write a follow-up letter
If you receive no response, send follow-up letters, with your original letter attached.