ConsumerInfo – Have a Complaint?

By Sally Praskey, Editor, Insurance Canada ConsumerInfo

You have a claim that you thought would be covered by your insurance. That's why you bought your policy in the first place, right? Yet your insurance provider is insisting that your claim is not covered under your policy. What do you do?

First, ask your insurance provider to show you exactly where in the policy it states that this particular peril is not covered. It may be that once you have read your policy, you will realize that you have no argument. (That's why it's so important to ask your insurance provider what is not covered before you buy your policy.)

However, many claims are not so cut-and-dried. Perhaps, having checked your policy, you still disagree with the insurer's decision. If so, try to resolve your problem within the company first. Discuss your case with a senior official in the claims department, the claims manager, if possible. This official may make an allowance if there is a grey area, particularly if you are a good long-term customer. But don't count on it.

If you're still not satisfied, find out if the insurance company (not the broker) has an ombudsperson or an employee who deals with consumer complaints. If so, contact that person.

General Insurance OmbudService

If you have followed these steps and your complaint still has not been resolved, there are other avenues to pursue. If your complaint concerns a licensed property and casualty insurance broker in Ontario, contact the Registered Insurance Brokers of Ontario (RIBO). Otherwise, contact one of the three members of the Financial Services OmbudsNetwork (FSON), a national, independent dispute-resolution system.

In the case of home, automobile, and business insurance, contact the General Insurance OmbudService (GIO). This service is available free of charge, in both English and French, to any policyholder in Canada. The majority of issues GIO deals with concern claims, interpretation of policy coverage, and policy processing and handling. Policyholders who have a dispute with one of GIO's member companies (which comprise most of the general insurance companies operating in Canada) can initiate the process by contacting GIO with the details of their complaint after they have first tried to resolve the problem directly with their insurance company. Consumers can access GIO's services by telephone (1-877-225-0446), mail, e-mail, fax, or through its Web site.

For more information, visit www.giocanada.org.

OmbudService for Life and Health Insurance

If you have a complaint about your life or health insurance, contact the OmbudService for Life and Health Insurance (OLHI). Like GIO, OLHI is an independent service to help consumers with complaints that they are not able to resolve by dealing directly with their insurance company. For more information, visit www.olhi.ca/.

Ombudsman for Banking Services and Investments

The third member of FSON is the Ombudsman for Banking Services and Investments (OBSI), an independent service for resolving banking services and investment disputes. For more information, visit www.obsi.ca.

Other options

In the case of property-claim disputes, you could also retain a public adjuster, a licensed adjuster who acts on your behalf to settle your loss with the insurance company, taking a percentage of the final settlement as payment. While public adjusters are not as common in Canada as they are in the United States, and the insurance industry – not surprisingly! – tends to shun them, they represent yet another avenue for dissatisfied consumers.

Finally, you may have to resort to legal action. If you retain a lawyer, choose one who specializes in insurance litigation, and ask in advance about fees. Lawyers' fees for bodily-injury lawsuits are usually payable upon settlement of the case, rather than on an hourly basis.

Communication the key

Most insurance disputes arise from a lack of communication upfront, when the insurance was purchased. Who can blame consumers for crying foul when, for example, they are penalized for making small claims that they probably wouldn't have made had they known the rules by which insurers play? It's the responsibility of the insurance provider, not only to explain these practices, but also to inform the consumer what is, and isn't, covered in the policy. Simply handing over a brochure to the consumer will not do the trick.

But policyholders must also learn to ask the right questions and make the effort to understand what they are buying. If your insurance provider is not willing to take the time to assess your needs, answer your questions, and explain your policy to you, find one who will. Ask trusted friends or relatives for recommendations, especially if they have experienced a recent claim. Insurance is a big expenditure, and you need to be sure you are getting what you're paying for – the peace of mind that comes from knowing you have the right insurance protection.