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Insurance company not covering claim

If something has gone wrong, then you will be relieved if you took out insurance to protect you against the risk.

However you and the insurance company may have different views about whether the event was covered by the insurance. Also you may not agree on what is a fair payment.

The law expects both you and the insurer to have acted reasonably. If the insurer will not fully cover your claim you may have to take legal action against them. However the first step is a written complaint letter. Some insurers will then be prepared to consider mediation. 

For disputes of £10,000 or less our small claims service should be able to help you. To get started here is a summary of the law and a sample complaint letter.

Your rights 

 

The insurance policy is an agreement or contract between you and the insurance company.  Your right is for the insurer to act reasonably and pay what you are entitled to.

The wording of your insurance policy is the starting  point of your rights  -  it states what you are entitled to receive from the insurance company:

1: Has an event occurred that is covered by the policy? Examples include a theft, a fire or an accident.

2: Have you complied with any requirements under the policy? There will often be requirements that you take certain steps to look after the insured item.

3: How much does the insurer have to pay out?

  • Is there a limit on the value of the type of claim?
  • Is there a “new for old” clause – if there is then your right is to receive from the insurer the cost of a replacement at current prices (new item to replace old item – but still subject to other terms and conditions)
  • If no “new for old” clause, then you are only entitled to receive either a repair or the second hand value of the item (its value just before the event) – whichever is cheaper for the insurer.

However an insurance company still have to act reasonably otherwise you may have a claim for their “breach of the insurance contract”
Also the law has also set some additional rules on how an insurance company must act – whatever the insurance policy says. Some examples are given below.

 

What do you have to prove to bring a claim?

 

1: That you have an insurance agreement with the insurer that covers the event. The insurer will tell you if they dispute that an event was covered.

  • However, if the wording is unclear, confusing or poorly explained then you may still be able to claim as your insurance company must give you clear information about the policy you are buying.

2: That you complied with any requirements under the policy? For example:
 That you took any steps required by the insurance to look after the insured item.

3: That you provided honest and relevant information before taking out the policy – so that the insurance company were not mislead in providing cover to you. This could be about storage of the property or other background information or history.

  • However, 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 they then say you should have voluntarily disclosed information they did not ask for then you may still be able to claim.

4: In relation to your actual claim, where you dispute the insurers’ valuation of what you are entitled to - you may have to provide your own evidence to support your valuation – such as 2 or 3 estimates for the cost of replacement or repair. 

 

What can you claim?

 

The amount you can claim will be what is “reasonable” in accordance with the rules of the policy

 

 

What is the deadline for starting a claim at court?

 

The policy will set the time within which you must report the event that you are claiming for. It will also set how you notify the claim to the insurer.

If you and the insurer cannot agree on what they should do or pay you under the policy then you usually have 6 years from the event to start court proceedings for the court to decide if the insurer has “breached the insurance contract” and what is reasonable in the circumstances.

 

Example claims

 

  • Insurer refusing to pay out anything as it says the event or situation was not covered by the insurance cover
  • Insurer refusing to pay for an item they say is  not included in the policy 
  • Insurer refusing to pay because of your failure to comply with the terms of the policy – such not disclosing relevant information

 

Disclaimer reminder

 

Please note: To give you general information about your dispute, the information given here is a simplification of a complex area of law and cannot be relied upon. Before taking action please use our Small Claims service to get specialist legal advice on your specific circumstances. See the full terms and conditions of this website

 

Information to include

Sample letter – Insurance company dispute
 
1

Start of official letter to other side.

[If you know the name of the person handling your dispute]: Dear Mr Smith, 

[If you do not know their name]: Dear Sirs,
 
2

Background

Any relevant background information:

What was agreed between you?

What happened (in date order)? 

 

Be specific and refer to any written or verbal agreements.  ​

 

Background

I took out an insurance policy with you on 7 May 2011, the most recent renewal was 7 May 2013. The current details are:

Policy number: 9515814-kh
Insurance type: Home contents insurance cover of £12,000.

I have checked the policy wording and it covers loss or damage to home contents including appliances. 

On 27 August 2013, there was an accident in my home which resulted in the TV falling from its stand and becoming damaged. I attach photos of the damaged TV. As you can see the damage is quite bad.

The TV is now no longer working and I would like to claim a replacement TV. 

On 28 August (within the claim notification period) I rang your claim service to register my claim.

On 30 August I completed and returned the claim form you sent to me – enclosing a copy of my receipt from 5 years ago when I bought the TV for £1,000.

Our insurance policy covers loss or damage to any appliance within the house. You are now stating that under the policy you are not obliged to replace the old TV with a new one.
 
3

Payments

Details of any payments requested and any payments made.

Payments

As required by the policy, I have made the monthly payments, which have been £42 since 7 May 2013. 
 
4

Complaint

Identify clearly why you are unhappy.

Give any relevant dates

Be clear about why you think the other person is responsible. 

Complaint

On 12 September 2013, one of your advisors called me. They advised:

  • You accepted the accident damaging the TV was covered by my policy.
  • You accepted that the TV was a 42” flat screen model (with no digital channels or internet access) that had cost me £1,000 5 years ago (in accordance with the receipt I provided).
  • You agreed my policy has a ‘new for old’ clause that you will be replacing the damaged TV with a new TV. 
  • You confirmed the excess on the policy means you will deduct £50 from my payment. I agree with this.

However you did not offer me £1,000 but just £200 – on the basis that the TV is now considered a very old fashioned model.
 
5

Problems caused

Give details of any problems you have suffered as a result.

If relevant refer to photos.
 

Problems caused

Whilst this dispute continues my family and I have been left without a TV in our living room.
 
6

Additional losses and expenses 

If the problems have caused you losses or expenses - give details.

Also provide proof of the damage and cost of repairs or replacement wherever possible.

Additional losses and expenses

None other than time and inconvenience.

However if the matter is not settled in the next 14 days I will buy the replacement TV described below from my savings and will claim back my lost interest.

 
 
7

Remedy

Be as clear as possible about the remedy you would like. 

  • Say what action you would like them to take (or stop). 
  • Where you are asking for a payment - put a price on the you seek.

Remedy

I accept the TV prices have come down in the last 5 years.

My particular model of TV is no longer made.

The nearest equivalent is the most basic 42” flat screen TV made by the same company - this is model GX42B.

As the attached information from the internet shows, the cheapest cost from a this (including delivery) is £495.  

I consider this to be a reasonable replacement under the terms of the policy. 

I therefore claim £495 less £50 excess = £445.
 
8

Reply

Give your opponent 14 days to reply to the letter – to  either:

  • agree with your complaint and give you the remedy that you seek 

OR 

  • arrange to inspect the problem (but only where relevant to the dispute)

OR

  • set out their detailed response.

Reply

Please do not ignore this letter. I would like us to try to resolve our dispute without court proceedings and legal costs.

Please reply in the next 14 days, so that this dispute can be resolved as set out in this letter. 

If you consider it necessary I am happy to agree a time with you for a member of your staff to inspect the TV at my home. Please telephone me to discuss the arrangements for inspection and repair within the next 14 days. The best daytime number to use is my mobile of 0799 043 732.

If you do not agree that you are liable and/or do not agree with the remedy sought, then please reply within 14 days with a detailed explanation of why not.

​
 
9

Consequences

Point out that ignoring your letter will mean you may start legal proceedings for the court to deal with the dispute and that you may refer the judge to your letter.

Consequences

I am sure it will not prove necessary but if I do not hear from you within 14 days then I reserve the right to start court proceedings without further reference to you. I will ask the court for an order that you pay me £445.00. 

If I do have to issue court proceedings, I will refer the court to this letter and I will also ask the court to order you to pay me interest, court fees and legal costs.

I look forward to hearing from you within the next 14 days.
 
10

Ending

[If you started with their name]:
Yours sincerely, 

Ian Rate

[If you started using Dear Sirs]:
Yours faithfully, 

Ian Rate

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