Three Options To Appeal A Rejected Insurance Claim

October 28, 2022October 28, 2022 olivesmith

Insurance or TPD claim rejection adds more pressure to an already stressed situation. If you disagree after your insurance claim is rejected, you should think about what actions might be done to contest or appeal the ruling. An outline of your legal options in the case of denied insurance claims is provided below.

IDR – Internal Dispute Resolution complaint

You have the right to directly appeal the rejected insurance claim to the person who made the initial decision, regardless of whether it was justified. Every super fund and insurance business has an internal appeals mechanism, and some even have sections explicitly dedicated to tackling these complaints.

Although IDR complaints are a valuable step, many customers are sceptical of internal IDR evaluations and think there is little use in appealing to the original decision-maker (i.e., the insurer or superannuation fund that initially denied their claim). Internal appeals of a super fund or insurance decisions frequently result in success, especially if we can get further relevant medical or other proof to be sent with the complaint.

According to revised guidelines, if you file an IDR complaint against a superannuation fund decision, the fund must answer within 45 days, if the complaint is over a decision made by an insurer alone, the insurer must react within 30 days.

AFCA – The Australian Financial Complaint Authority

One alternative for appealing a refused insurance claim is to file an appeal with AFCA. It is required that a complaint be made to the superannuation fund or insurance first before submitting it to AFCA.

The statutes that regulate how the AFCA handles complaints against insurance and superannuation institutions vary, as do the deadlines for filing them, but the process remains fundamentally the same:

A case manager is appointed in the majority of AFCA complaints, and parties exchange paperwork and submissions.
Conciliation is usually present (held via telephone).
The case manager often suggests a result that they believe is fair and reasonable under the applicable legislation if the conciliation doesn’t settle the complaint.
If both or all of the complainants approve the recommendation, it becomes legally binding. If not, the case will proceed to a final judgment 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 elect to pursue further legal action if you are not satisfied with the result. It’s significant to note that only judgments concerning superannuation funds may be challenged in the Federal Court on legal issues.

Court action

If your insurance claim is denied, you may have the option to file a court claim (sometimes also called litigation). You may launch a lawsuit if an insurance claim is refused and includes either an insurer acting alone or both an insurer and a superannuation fund. The method is practically the same for both. Claims in court must be submitted within particular time limitations.

All Australian states and territories have a variety of courts where lawsuits can be filed. The procedure for filing court claims differs by state. Furthermore, there are differences in how court matters are handled in different jurisdictions within the same state.

The majority of court cases go as described in the following broad overview:

To begin the claim, a statement of claim or other official document is filed with the court (sometimes also called a proceeding).
Then, a response to the statement of claim must typically be filed by the insurer and/or superannuation fund (or equivalent). The term “defence” generally refers to this text.
Following then, all pertinent papers that the parties have will typically be exchanged. The term disclosure or discovery refers to this procedure.
Mediation is often held after the parties have obtained and exchanged the expert and medical evidence they are relying on to support their claim.
If mediation fails to resolve, the case will move forward to a full court hearing, typically in front of a judge alone.

Several other phases might occur. Interrogatories, for instance, may be traded. In this process, each party is asked several questions, the answers to which must be provided on oath. To get comprehensive copies of your medical records, the parties may also submit and serve subpoenas on your doctors.

You should look into your possibilities for an appeal if your insurance claim is denied or you feel that the decision was incorrect. It is reasonable that it may be intimidating and sometimes complicated, but you can choose services that can help you regardless of the kind of insurance claim that has been denied. Therefore, opting for an insurance Lawyer would be beneficial for you to make good decisions. You can also opt for a superannuation lawyer in Sydney who would guide you through the process in an effective way.