Receiving a letter of denial from an insurance company is never a welcomed outcome for anyone, particularly when you feel the insurance claim is legitimate.
If you do not agree with the reason your claim has been denied, or you feel the insurer’s decision lacks sufficient reasoning, you will always have the means available to escalate the matter further.
There are two levels of escalation available:
1. IDR – Internal Dispute Resolution
2. AFCA – Australian Financial Complaints Authority
It is our job to scrutinise all claim denials which are received on behalf of Whitbread clients. We then evaluate whether the insurer’s denial falls within the scope and intent of the policy issued. If there are grounds for an appeal, we will go back to the insurance company and request that they review their decision.
Often the insurer’s position is well substantiated, however there are times when the denial is not right and for us, that’s when the challenge begins!
Our next moves are to:
- Apply the doctrine of proximate cause
- Review the policy wording, paying particular attention to policy definitions, conditions and exclusions
- Review all relevant documentation such as assessor reports, or the claim form
- Evaluate the reason for the denial
- Seek further particulars from the claimant where necessary
- Apply precedent whereby insurers have previously paid claims with similar circumstance
If after reviewing all the above, we are of the belief that the claim should be paid, we will advise you that it is in your best interests that this claim should be submitted to IDR.
The review process is handled by the Internal Dispute Resolution (IDR) body within the insurance company. They then have 15 days to advise whether the initial decision will stand or be overturned. In the event that the claim ruling stands, and you feel the IDR body’s reasoning is unsatisfactory, then we will advise you to escalate the claim to the Australian Financial Complaints Authority.
Why does a claim ruling get overturned by IDR?
At the end of the day we are relying on humans to interpret policy wordings and definitions, and this can sometimes lead to a lack of consistency.
The IDR process enables us to submit further substantiating information which may not have been provided at the time of lodgement. Our job, as a broker, is to always advocate on your behalf to reach the best possible outcome.
Our claims department are highly skilled in handling such disputes, with the team comprising professionals who have worked within insurance companies, Financial Ombudsmen Services, as well as insurance brokers.
To date we have been very successful on IDR’s with more than half the denials that we pursue overturned either in part, or in total.
If you feel as though you have been hard done by and had a claim unfairly denied by your insurer, we encourage you to let us know so we can assist by providing advice and if applicable, escalating the matter further.
Your interests are in our best interests.
For more information on IDR’s, please contact Whitbread Insurance Brokers on 1300 424 627 or email info@whitbread.com.au
This article is not intended to be personal advice and you should not rely on it as a substitute for any form of personal advice. Please contact Whitbread Associates Pty Ltd ABN 69 005 490 228 License Number: 229092 trading as Whitbread Insurance Brokers for further information or refer to our website.
