The Financial Ombudsman Service (FOS) provides a dispute resolution scheme to help people in disputes with their insurance companies.
Advantages of dispute resolution schemes
The advantages of using a dispute resolution scheme rather than going to court are:
- they are familiar with insurance law
- they are free
- you do not need a lawyer to use them
- they will help investigate the complaint
Complaints against brokers
For complaints against insurance brokers the Insurance Brokers Dispute Facility is the relevant scheme to deal with disputes (see Complaints about brokers).
The complaints process
Before going to Financial Ombudsman Service you must attempt to resolve the complaint with your insurer directly.
The internal review by the insurer is not window dressing. If a complaint is taken to the Financial Ombudsman Service the insurer will have to pay a fee, so it has an economic incentive to establish proper internal complaint resolution procedures.
If the matter cannot be resolved with the insurer it may then be taken to the Financial Ombudsman Service, which will conduct an investigation.
If the complaint is not settled or conciliated at this stage, it is referred to a panel of the Financial Ombudsman Service (FOS).
What the panel will consider
The terms of reference of the FOS require the panel to give consideration to 'what is fair and reasonable in all the circumstances, to good insurance practice, the terms of the policy and established legal principle'.
It may therefore be possible to argue that a claim should be paid because the conduct of the insurer was unreasonable or unfair, even if it was legal.
Making a submission to the panel
The following points should be addressed in a submission to the panel:
- The letter of complaint should clearly state why the claim should be paid. It should specifically address any reasons the insurance company has given for refusing the claim or rejecting the complaint.
- If the claim depends on what was said between the consumer and the insurer, the conversations should be reported as precisely as possible. Any supporting details should also be provided, such as information that would make it more likely that the consumer should be believed (for example, the person relied on oral statements because they could not read English).
- If it is being argued that the person did not receive various documents (and that, for example, the insurer should pay because it breached s.35 of the Insurance Contracts Act), the history of the sale of the policy should be set out in detail, identifying what documents were received.
The panel's decision
The decisions of the Financial Ombudsman Service are not binding precedents. Each case is considered individually on its facts.
The panel's decisions are not binding on consumers either - a person who is dissatisfied can reject the decision and pursue court action.
The content of the Law Handbook is made available as a public service for information purposes only and should not be relied upon as a substitute for legal advice. See Disclaimer for details. For free and confidential legal advice in South Australia call 1300 366 424.