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Insurance company denying to pay claim
20-Oct-2023 (In Insurance Law)
Our company owes a JCB machine (excavator) and was working at site, one evening it met with an accident wherein it caused death for a person. Few days later compensation case was filed by the dependents of the deceased and then under-mentioned was learnt by us: 1) Insurance was valid with Bajaj Insurance 2) Insurance was CPM policy and not motor policy with 10% third party liability (maximum) 3) JCB was registered with having registration number issued from Motor Vehicle department. the deceased was government employee and compensation is around 44 lacs and insurance company has filed reply stating their liability is minimum. We seek recourse as to how we can make insurance company liable Please suggest suitable remedy
Check your policy documents
Check the details of your policy to see if the facts fit the reason for the rejection.
Check you gave all the correct details in the beginning.
Note down or highlight the exact wording in your policy that says you’re covered – you’ll need it later.
If the wording is ambiguous or poorly explained, note that down too. Your insurance company is duty-bound to give you clear information.
New rules state that an insurance company can’t reject your claim if you took reasonable care to answer all their questions honestly and to the best of your knowledge. If your insurer didn’t ask for information they now say you should have voluntarily disclosed, note that down too.
Then find any other documentation that relates to your policy. For example, if you sent your insurance company a letter advising them of a change in your circumstances (this is your responsibility), try to find a copy of the letter.
Contact the insurance company
Once you’ve taken a look at your policy, it’s time to get in touch with the insurance company. You can phone the company and speak to their complaints handlers or write a formal letter of complaint and send it to the contact given in the company’s complaints procedure.
How to write a formal complaint letter
Use our letter template (DOC 30KB) or follow the tips below to write your letter of complaint.
Mark the letter ‘complaint’ clearly at the top
Put the date on the letter
Give your name and policy number
Explain your complaint clearly, stating why you think your claim should not have been rejected
Include any evidence you have to support your complaint
Say what you would like the company to do to put things right
State that if you are unhappy with the company’s response you will take the matter to the Financial Ombudsman Service (see below)
Get an independent assessment
If the problem is technical or specialist – for example, if your insurer is arguing that damage to your property was as a result of wear and tear and you’re arguing that it was accidental damage – it may help to get an independent assessment. Get a loss assessor (sometimes called a loss adjuster) in to look at the damage and send their report to the insurance company as evidence. They will charge a fee for representing you.
Find a loss adjuster near you on the Chartered Institute of Loss Adjusters website
Even if it doesn’t change the insurance company’s mind, it may be useful information to have later on.
Go to the Ombudsman Service
If, after going through the insurance company’s complaints process, you are still unhappy with the outcome, you have a right to take your complaint to the Financial Ombudsman Service. You can only do this once you have received what’s called a ‘final response’ from your insurance company, or eight weeks have passed and you haven’t received a response from them.
The Financial Ombudsman Service is an independent, free service that investigates complaints from individuals about financial companies. If you take your complaint to them they’ll consider both sides of the story, look at the documentation and attempt to find a fair outcome based on the facts and common sense.
If they decide your claim was wrongly rejected, the Ombudsman Service has the power to make the insurance company:
Explain their actions
Apologise, and
Pay compensation or take appropriate steps to change the outcome
Download and complete a complaint form from the Financial Ombudsman Service website. Send it off with a copy of the final response letter from your insurance company plus any other documents you have that support your case.
Find out how to complain to the Financial Ombudsman Service on their website
Your case will first of all be looked at by an ‘adjudicator’ but if either you or your insurance company is unhappy with the outcome, it can be referred up the chain to an ‘Ombudsman’. The Ombudsman’s decision is final and binding on the insurance company. If you’re unhappy with the outcome, you will still have the right to take your case to court.
Check the details of your policy to see if the facts fit the reason for the rejection.
Check you gave all the correct details in the beginning.
Note down or highlight the exact wording in your policy that says you’re covered – you’ll need it later.
If the wording is ambiguous or poorly explained, note that down too. Your insurance company is duty-bound to give you clear information.
New rules state that an insurance company can’t reject your claim if you took reasonable care to answer all their questions honestly and to the best of your knowledge. If your insurer didn’t ask for information they now say you should have voluntarily disclosed, note that down too.
Then find any other documentation that relates to your policy. For example, if you sent your insurance company a letter advising them of a change in your circumstances (this is your responsibility), try to find a copy of the letter.
Contact the insurance company
Once you’ve taken a look at your policy, it’s time to get in touch with the insurance company. You can phone the company and speak to their complaints handlers or write a formal letter of complaint and send it to the contact given in the company’s complaints procedure.
How to write a formal complaint letter
Use our letter template (DOC 30KB) or follow the tips below to write your letter of complaint.
Mark the letter ‘complaint’ clearly at the top
Put the date on the letter
Give your name and policy number
Explain your complaint clearly, stating why you think your claim should not have been rejected
Include any evidence you have to support your complaint
Say what you would like the company to do to put things right
State that if you are unhappy with the company’s response you will take the matter to the Financial Ombudsman Service (see below)
Get an independent assessment
If the problem is technical or specialist – for example, if your insurer is arguing that damage to your property was as a result of wear and tear and you’re arguing that it was accidental damage – it may help to get an independent assessment. Get a loss assessor (sometimes called a loss adjuster) in to look at the damage and send their report to the insurance company as evidence. They will charge a fee for representing you.
Find a loss adjuster near you on the Chartered Institute of Loss Adjusters website
Even if it doesn’t change the insurance company’s mind, it may be useful information to have later on.
Go to the Ombudsman Service
If, after going through the insurance company’s complaints process, you are still unhappy with the outcome, you have a right to take your complaint to the Financial Ombudsman Service. You can only do this once you have received what’s called a ‘final response’ from your insurance company, or eight weeks have passed and you haven’t received a response from them.
The Financial Ombudsman Service is an independent, free service that investigates complaints from individuals about financial companies. If you take your complaint to them they’ll consider both sides of the story, look at the documentation and attempt to find a fair outcome based on the facts and common sense.
If they decide your claim was wrongly rejected, the Ombudsman Service has the power to make the insurance company:
Explain their actions
Apologise, and
Pay compensation or take appropriate steps to change the outcome
Download and complete a complaint form from the Financial Ombudsman Service website. Send it off with a copy of the final response letter from your insurance company plus any other documents you have that support your case.
Find out how to complain to the Financial Ombudsman Service on their website
Your case will first of all be looked at by an ‘adjudicator’ but if either you or your insurance company is unhappy with the outcome, it can be referred up the chain to an ‘Ombudsman’. The Ombudsman’s decision is final and binding on the insurance company. If you’re unhappy with the outcome, you will still have the right to take your case to court.
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Adv. Siddhant Sharma
Delhi | 500+ Answers
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Disclaimer: The above query and its response is NOT a legal opinion in any way whatsoever as this is based on the information shared by the person posting the query at lawrato.com and has been responded by one of the Divorce Lawyers at lawrato.com to address the specific facts and details.
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