Resolution of insurance disputes

Litigation through the court process is one way of resolving insurance disputes, but it is often costly and time consuming. A number of organisations deal with various kinds of insurance disputes so long as the complaint is not or has not been referred to the courts. They provide a number of alternatives to litigation for policyholders.

Section 10 of the Code sets out processes for the internal and external resolution of disputes with insurers.

Financial Ombudsman Service

The Financial Ombudsman Service (FOS) is an independent forum that assists in resolving disputes between consumers and member financial services providers. Membership to the FOS is open to any financial service provider conducting business in Australia. The dispute resolution process covers financial services disputes involving disputes relating to banking, credit loans, general insurance, life insurance, financial planning investments, stockbroking, managed fund and pooled superannuation funds.

The FOS is a free national service open to all consumers.

In respect of insurance disputes, the FOS can only consider a dispute that arises from or relates to an entitlement or benefit under a general insurance policy by a person who is specified or referred to in the policy (whether by name or otherwise) as a person to whom the policy extends.

There are limitations in respect of a general insurance policy. The FOS may only consider a dispute in relation to a general insurance policy that is either a:

a retail general insurance policy (this includes the insurances listed in “Eligible contracts”);

b residential strata title insurance product;

c small business insurance product; or

d medical indemnity insurance product.

Other disputes with insurers and insurance brokers may be dealt with but only with the agreement of all parties. In respect of a general insurance policy, the FOS may not consider a dispute about rating factors and weightings the insurer applies to determine the insured’s or proposed insured’s base premium, which is commercially sensitive information.

There are limitations in respect to insurance disputes. The FOS may also not consider a dispute regarding a decision to refuse to provide insurance cover except in the circumstances where the dispute is that the decision was made indiscriminately, maliciously on or the basis of incorrect information, or where the dispute relates to medical indemnity insurance cover.

From 1 January 2015, FOS can accept claims up to $500,000, however the maximum total FOS can award is:

for claims made on life or general insurance policies dealing with income stream risk or similar advice: $8,300 per month;

for uninsured third-party motor vehicle accident claims: $5,000;

for claims against a general insurance broker (except where the claim relates solely to a life insurance policy): $166,000; and

for all other claims: $309,000.

The FOS will first encourage consumers to attempt to resolve their dispute through the insurer’s internal dispute resolution process. If this is not successful consumers must then contact FOS and they will assess whether the dispute can be handled by FOS.

The FOS may initially manage the dispute through negotiation and conciliation. Otherwise, the FOS will investigate the claim and issue a Recommendation. In assessing a dispute, the FOS will take into account legal principles, applicable industry codes and guidelines, good industry practice and previous relevant decisions of the FOS. The FOS may also take into account specialist input.

A Recommendation is a preliminary decision on the merits. The FOS will ask the parties to consider the Recommendation and consider accepting it. Parties have 30 days to agree on the Recommendation. Otherwise, the FOS will proceed to a Determination. A Determination is a final decision on the merits. (For information about merits reviews, see Appealing government and administrative decisions.)

Consumers are not bound to accept a Determination of the FOS. However, if the consumer wishes to accept a Determination, it must inform the FOS and the financial services provider within 30 days.

Financial services providers are bound by a determination of the FOS.

Financial Ombudsman Service

General Insurance Division

GPO Box 3, Melbourne Vic 3001

Tel: 1800 367 287

Email: info@fos.org.au

Web: www.fos.org.au

Disputes can also be lodged online

Small claims

Small claims are now heard in VCAT’s Civil Claims List (seeSmall claims: VCAT’s Civil Claims List” in Taking action as a consumer).

VCAT offers a simple and inexpensive way for policyholders to resolve disputes. It may not hear a claim that has already been taken to court.

VCAT will arrange for a hearing of the policyholder’s dispute and policyholders may seek legal help to prepare themselves for the hearing. In small claims, the policyholder (and insurer) will not be able to have a lawyer act for them at the hearing but may be represented by a friend or by a worker from a community organisation.

For information about fees for referring matters to VCAT and all other enquires, contact:

Victorian Civil and Administrative Tribunal (VCAT)

Civil Claims List

55 King Street, Melbourne Vic 3000

Tel: 9628 9830; 1800 133 055

Email: vcat-civil@vcat.vic.gov.au

Web: www.vcat.vic.gov.au

Australian Prudential Regulation Authority

The Australian Prudential Regulation Authority (APRA) is the prudential regulator of banks and other authorised deposit taking institutions, insurance companies and superannuation funds. It is a statutory authority whose board includes representatives from the Reserve Bank and the Australian Securities and Investments Commission.

Policyholders who believe their grievance has not been properly managed by the insurer should contact APRA for advice. APRA will not resolve the dispute but will advise the policyholder on the appropriate course of action.

Within APRA, general insurers are supervised by supervision groups within both the Diversified Institutions Division and the Specialised Institutions Division. Policy issues are dealt with by the General Insurance Cross Divisional Committee.

Australian Prudential Regulation Authority (APRA)

Level 21, Casselden Place, 2 Lonsdale Street,

Melbourne Vic 3000

Tel: 9246 7500; 1300 558 849

Web: www.apra.gov.au

Contacts and resources