Has your insurance claim been rejected?

An insurer’s decision to reject a claim is not necessarily the end of the matter.

The outcome may depend upon the precise wording of the policy, the circumstances in which the policy was arranged, the evidence supporting the claim, the insurer’s reasons for its decision and the application of the relevant insurance legislation and common law.

We can review the policy and claim history, identify the issues in dispute and advise you on the available options.

In appropriate cases, this may involve challenging the insurer’s decision through negotiation, an internal dispute resolution process, the Australian Financial Complaints Authority (AFCA), or court proceedings.

Insurance claims are often won or lost on preparation

Insurance disputes can involve substantial documentation and complex factual and medical evidence.

Our approach is to identify the real issues early and build the evidence needed to address them. Depending upon the nature of the claim, this may involve reviewing:

• the insurance policy and policy schedule;

• the proposal and underwriting information;

• correspondence with the insurer or broker;

• claim forms and claim investigation material;

• medical records and expert reports;

• financial and accounting records;

• loss-adjuster’s reports;

• photographs and other evidence of damage;

• business interruption calculations; and

• the insurer’s reasons for accepting or declining the claim.

Where appropriate, we work with specialist experts to establish the value and nature of the loss.

Business insurance disputes

For a business, an insurance dispute can become a business survival issue.

A major fire, flood, storm, equipment failure or other insured event can interrupt trading and create significant additional expenses. The dispute may therefore extend beyond the immediate physical damage to questions concerning business interruption, additional increased costs of working, alternative premises, loss of profits and other policy benefits.

Lee Lawyers has experience assisting businesses with insurance claims preparation, business interruption claims and coverage issues following major insured events.

We can assist businesses both before making a claim and when a claim has become disputed.

Life, TPD and income protection disputes

Life, total and permanent disability and income protection claims can have profound financial consequences for individuals and their families.

Insurers may dispute whether the insured satisfies the policy definition, question medical evidence, rely upon exclusions or investigate historical medical information and alleged non-disclosure.

Lee Lawyers has acted in technically difficult insurance matters involving income protection and TPD insurance. In one substantial matter, we challenged an insurer’s reliance upon historical medical information and ultimately resolved the dispute at mediation after proceedings had been commenced in the Supreme Court of Queensland.

We understand the insurer’s perspective

Insurance disputes are different from many other forms of litigation.

The policy wording, underwriting history, claims process and insurer’s internal assessment can all be critical. Our Principal’s previous insurance-industry experience provides a practical understanding of how claims are assessed, investigated and managed, which can assist in identifying the real issues in dispute.

Our objective is not simply to commence proceedings. Where possible, we seek to understand the dispute, establish the evidence and pursue the most effective pathway to resolution.

That may be a carefully prepared letter of demand, negotiation or mediation. Where necessary, we are also experienced in conducting litigation.

Early advice can make a difference

If an insurer has rejected your claim, asked you to provide further information, raised an issue about non-disclosure or indicated that your policy may not respond, it is sensible to obtain legal advice before the dispute becomes entrenched.

We can review the position and advise you about:

Is there cover?
Whether the policy potentially responds to the event or loss.

Why has the insurer declined the claim?
Whether the insurer’s reasoning is supported by the policy and the available evidence.

What is the claim actually worth?
Whether the insurer’s assessment properly reflects the insured loss and available policy benefits.

What should happen next?
Whether the appropriate course is negotiation, internal review, AFCA, mediation or litigation.

A practical, strategic approach

At Lee Lawyers, we aim to give clients clear advice about both the legal position and the practical consequences of the available options.

We understand that most clients do not want a prolonged legal battle. They want their insurance claim properly assessed and, where possible, resolved efficiently.

Where litigation is necessary, however, we have substantial experience prosecuting and defending civil claims and regularly appear in Queensland courts.