Resolving insurer disputes: get assistance for insurance issues

If a client cannot resolve a dispute with their insurer, or feel they have been unfairly treated, the insurance Ombud is there to help find a fair resolution to the problem. We find out more about Ombuds and how to get assistance if you need it.

While this article focuses on the Ombudsman for Long Term Insurance, the same principles apply to other Ombud services such as the Ombudsman for Short Term Insurance.

What do Ombuds do?

• Ombud’s offer their expert services to consumers who feel they have been unfairly treated and cannot find a resolution to their problems with the company they have a problem with
• Ombud’s offices are staffed by industry experts and legal specialists, and are frequently headed by retired judges
• Ombud’s services are free for consumers, which makes them the only option for most of us who cannot afford expensive legal fees
• Ombud’s aim to find quick, fair resolutions to problems
• Ombud’s reach binding solutions which means the parties must agree to follow their recommendations. This doesn’t mean their findings can’t be disputed, they can, but it is rare to find a recommendation overturned.

How to complain to an Ombud

The different Ombuds deal with different sectors such as the Long-Term Insurance Ombudsman for long term insurance policies. Always check you are complaining to the right Ombud, which you can do by checking their website or calling them.

Ombuds have limited staff so they have specific rules for complaints including who can complain, about what and when.

What you can complain about

Different Ombuds have their own sectors or industries. Check the Ombud’s website, or call them, to see what type of complaints they deal with in their sector. The Ombudsman for Long Term Insurance can deal with queries relating to a long-term insurance policy such as life cover or funeral cover, and how these policies are administered.

Follow the company’s complaints procedure

Before you raise your complaint with the Ombud you must raise your problem with the company you are dealing with and follow their complaints procedures. So, if you have a complaint about an insurer your first port of call is the insurer. Only if you cannot find a satisfactory solution or disagree with the insurer and can take the matter no further should you refer it to an Ombud. When Ombuds receive complaints that have not been raised with the company they either reject these or refer them back to the company in question.

Have detailed records of the facts of your case

The Ombud will want the facts of the case, and to know what steps you have taken to find a resolution.

When you ask an Ombud for assistance include records with dates and details of:

• Policy information, such as the insurer, policy number, policy benefits and sum assured
• The problem, such as claim rejected
• Why you feel you have been treated unfairly
• Who and when you contacted in the company to try and resolve the issue, and their response
• Why you are still dissatisfied with the company’s response and actions

Remember to include details of all correspondence such emails and phone calls and include all the facts. The more detail you include the less investigative work the Ombud should need to do. 

Complain promptly

When you have a problem, raise it and deal with it or refer it to an Ombud as soon as possible. If a complaint relates to a matter a few years back an Ombud may reject it.

Visit the Ombuds’ website for contact details and advice on how to complain

The website for the Ombudsman for Long Term Insurance has details on how to complain. You can also call the Ombud’s office.

What should you expect when you complain?

The Ombud will acknowledge your complaint and let you know they are dealing with it.

Ombuds like to find quick resolutions, but they also take their time to investigate so they can come to a fair and equitable solution. The Ombudsman for Long Term Insurance resolved 53% of their cases in 60 days in 2019. 31% took over 90 days to resolve.

Ask when you can expect feedback and make a note of any case or reference number you can use when you contact them.

Remember, the Ombud may not find in your favour, they may find in favour of the company.

When things don’t go smoothly Ombuds are there to help

Insurers such as 1Life are committed to treating customers fairly and making sure we offer the best possible cover at the best price, settle valid claims timeously and offer products that meet our clients’ needs. If we don’t live up to this standard and cannot resolve your complaints satisfactorily the Ombud is there to help.