Did the insurer reject your insurance claim? Or perhaps your insurance claim is denied by the insurer? Do not fear; we will assist you in understanding your other choices.

You don’t have to accept a fund’s or insurer’s denial of an insurance claim, whether it’s for TPD, income protection, house insurance, or any other claim. If you disagree with the decision to have your insurance claim rejected or denied, you should think about what actions can be taken to question, challenge, or appeal the ruling. The following article provides an outline of your rights in the event of insurance claim rejection.

Internal Dispute Resolution (IDR) complaint if Insurance Claim is Denied

Whether the rejected insurance claim is:

  • Income protection or TPD claims made through superannuation claims;
  • claims made directly to an insurer (such as TPD insurance outside of super);
  • a claim for life insurance or for other types of insurance (for example, home and contents, motor vehicle insurance, travel insurance etc),

You are entitled to immediately appeal the denied claim to the person who made the initial decision.

Every super fund and the insurance company has a procedure for processing internal appeals, and some even have divisions specifically designed to handle these concerns.

IDR complaints are a useful step, however many consumers are sceptical of internal assessments of IDR complaints and believe there is little purpose in appealing to the original decision-maker (i.e. the insurer or superannuation fund that was initially denied to claim). Internal appeals of the super fund or insurance decisions frequently result in success, especially when we can get further supporting medical or other evidence to be transferred along with the complaint. It is best to consult with insurance claim lawyers if you have limited knowledge about IDR and want to file one.

The Australian Financial Complaint Authority (AFCA)

An appeal to AFCA is one option for appealing a denied insurance claim. Before filing an appeal with AFCA, a complaint must be addressed directly to the superannuation fund or insurance.

The laws governing how the AFCA processes complaints against insurance and superannuation funds change, as do the deadlines for filing complaints, but the process is essentially the same:

1) In the majority of AFCA complaints, a case manager is appointed, and parties exchange paperwork and submissions. Usually, there is conciliation (held via telephone).

2) The case manager often makes a suggestion regarding the result they believe is fair and reasonable under the applicable legislation if the conciliation doesn’t settle the complaint.

3) If both or all of the parties to the complaint accept the suggestion, it is legally binding. If not, the complaint will move on to a final ruling that is made by an ombudsman.

If accepted by you, a resolution is legally obligatory on the super fund/insurer and must be followed. However, you are not required to accept the determination and may opt to pursue further legal action if you are not satisfied with the result. It’s important to note that only judgments concerning superannuation funds may be challenged by the Federal Court on legal issues.

Court action against a denied insurance claim

If your insurance claim is denied, you may have the option to file a court claim (sometimes also called litigation). If an insurance claim is denied and involves either an insurer acting alone or both an insurer and a superannuation fund, you may file a lawsuit. For both, the procedure is essentially the same. Court claims must be filed within specific time frames.

All Australian states and territories have several courts where lawsuits can be filed. The process for filing court claims varies from state to state. Additionally, there are variations in how court cases are handled in various jurisdictions within the same state (ie the Supreme Court in NSW is different to the District Court in NSW).

Seek assistance from an insurance lawyer if you are unsure of how to submit a claim denial for insurance coverage. They can assist you in comprehending all applicable local legislation and how to submit a successful claim.

You should look into your possibilities for an appeal if you feel that the decision to deny your insurance claim was wrong. No matter what kind of insurance claim has been denied, we can help you. We recognise that the process can be overwhelming and sometimes confusing. Unlike other legal companies, WKB TPD Lawyers only handle TPD cases. Furthermore, we ensure to assist you in obtaining only successful insurance claims.