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Why does the complaints process take so long? What are the processes?

The basic procedure is:

  1. The Ombudsman’s office receives and studies your initial complaint and
    • if it falls within the office’s jurisdiction, an application form is sent to you, and a reference number is allocated. Please use our reference in all correspondence.
    • If the office cannot assist you, we will nevertheless reply to your letter and make an informal suggestion as to what you might or can do.
  2. Once you have returned the completed Application for Assistance form, the office will send you an acknowledgement in writing. All Insurers have now agreed to suspend time limits while the matter is formally in the Ombudsman's office. At the same time the office will give the Insurer a formal notification that an official complaint has been received and requests the insurer’s formal response to the complaint.
  3. The insurer’s formal response is then awaited and once received, the Application is then studied in detail. There is an inevitable delay at this stage. Some Insurers are swifter than others in replying and reminders are sometimes needed. When the reply is received, the Ombudsman’s office may ask for further details and / or documents.  In addition to considering applications, the office’s working day includes correspondence under (1) (b) above, despatching of reminders, making and receiving telephone calls from the public, insurers, and brokers, and attending meetings between the parties,
  4. The complainant is now requested to comment on the insurer’s response and/or to provide further information and /or documents.
  5. Once the Ombudsman’s office is in receipt of all the necessary information to make a decision on the complaint, we may:
    • make a finding in favour of the insurer, where the rejection of the claim is justified and in accordance with the policy wording;
    • if the circumstances are such that we feel a meeting could resolve the matter, then one is arranged;
    • if it is clear that the dispute simply revolves around a legal interpretation of policy conditions and their effect, give a formal ruling or recommendation, one way or the other;
    • when there is a clear dispute of expert evidence or material fact which can only be decided by evidence, decline to give a ruling either way;
    • where legally or technically the Insurer's contentions are strictly correct, but in the opinion of the Ombudsman equity or special circumstances or proper sound insurance practice require that consideration should be given to an amicable settlement or compromise, the Ombudsman will endeavour to persuade the Insurer to take this course, and in a proper case may even make an equitable ruling to that effect.

Everything set out above takes time. Insurers do not lightly repudiate claims or reduce amounts claimed, and when they do, it takes a good deal of debate and negotiation to persuade them that the matter warrants reconsideration. Similarly, the Ombudsman will not lightly make a formal recommendation either way, and when he does, it will only be after the fullest consideration.

The Ombudsman is fully aware of the difficulties (financial and otherwise) when a claim is rejected. Normally if you decide to go ahead with legal action, it will take much longer to reach a decision, and you will run the risk of having to pay substantial legal costs, especially if the Court's decision goes against you. However, if you feel that you cannot afford to wait, you have every right to try legal proceedings or any other lawful means to bring about the result you want.

If you want to use the Ombudsman, the time from filing the claim until a decision or recommendation is made may vary from three months to a year or more, depending on the circumstances and the complexity of the matter. The Ombudsman is making every effort to expedite the whole system, and whatever the result, will also make every effort to preserve your right to take legal action should the outcome not be favourable to you.