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How to Resolve a Dispute with your Insurance Company

March 25, 2011

As careful as we are, there is the possibility of being involved in an accident while you’re driving.   Or having damage occur to your home due to circumstances you can’t control.   While carrying car insurance and home insurance minimizes the financial risks and responsibilities of the aftermath of an accident, there is a possibility that you and your insurance company could disagree about the benefits you’re entitled to in the event that you have to file a claim.   What can you do in the case of a dispute with your insurance company?   The best scenario is that you and your insurance provider can come to an agreement that works for both of you, but in the case that it isn’t possible to resolve the disagreement between both parties, there are other options available to you.

For insurance in Ontario, disputes are handled by the Dispute Resolution Services branch of the Financial Services Commission of Ontario (FSCO).   The FSCO offers several steps to resolve your dispute:

  • Mediation
  • Neutral evaluation
  • Arbitration
  • Appeal
  • Variation/revocation

Let’s look at each step in more detail:

Mediation

Mediation is an informal process where you and a representative from the insurance company sit down with a neutral mediator to discuss your case.   A mediation meeting can be conducted in person or over the phone.   You or a representative, who is authorized to enter into an agreement on your behalf, must be present for all mediation meetings. The mediation process will normally be completed within 60 days from when your application is complete.   This limit can be extended if both parties agree in writing.

To be eligible you must file for mediation within two years of the insurance company’s refusal to pay your claim.   There is no cost for mediation, although you will be responsible for your own personal expenses, such as travel, lawyer’s fees, medical reports, and so on.

Once the mediation process is finished, the mediator will issue a summary of the process called the Report of Mediator.   This report will identify which issues have been settled, which issues are still under dispute, and the steps that can be taken next.

Neutral Evaluation

A neutral evaluation is an option that you and your insurance company may agree upon to resolve the dispute.   It involves hiring a private evaluator, agreed upon by both you and your insurance company.   The evaluator then reviews the mediation process and gives an opinion on what would likely happen is the dispute went to court.   This decision is non-binding, so you can choose to settle based on the evaluation, or pursue the matter further through arbitration or a court case.

Arbitration

If your dispute is not resolved through mediation, the next step is to apply for an FSCO appointed arbitrator.   This application must come from you, and cannot come from your insurance company.   To be eligible, you need to apply within two years of the insurance company’s refusal to pay your benefits, or 90 days after the Report of Mediator, whichever is later.   Your application must include the $100 fee for arbitration, and the Report of Mediator or Report of Neutral Evaluator, or it will be declined.
You will have to attend a pre-hearing conference with the arbitrator to discuss your case.   The arbitrator will try to help settle your case before a formal hearing is needed, but if that is not possible, a hearing date will be scheduled.   Unlike mediation or neutral evaluation hearings, the arbitrator’s decision is binding on both parties in the dispute.

Appeals

You can appeal an arbitration ruling within 30 days of the award, but only if you are disputing a point of law.   That is, if you (or more likely, your legal counsel) feel that there was a legal technicality involved that adversely affected the arbitrator’s decision.

Both you and the insurance company are entitled to initiate an appeal.   There is a $250 fee to file an appeal and the insurance company must pay an additional $500 for every appeal in which they are involved.   Depending on the outcome of the appeal, you may be asked to pay the insurance company’s expenses related to the appeal, they may be asked to pay your expenses, or you may both be required to pay your own expenses.

Variation and Revocation

Both you and your insurance company can file for a variation or revocation of an arbitration or appeal result for one of three reasons.

1. There has been a change in your circumstances that affects the arbitration result.
2. New evidence becomes available.
3. There is an error in the arbitration ruling or appeal.

You can apply for a variation or revocation of an appeal order by submitting the proper forms and a $250 processing fee.   The insurance company has 20 days to respond to your request for variation or revocation of an appeal.   This may result in a new binding arbitration order.

Hopefully, you will never need to file for dispute resolution with your insurance company, but if you do the FSCO has a well documented system in place to ensure that you get a fair hearing.   The more information and documentation you can provide to the mediator or arbitrator, the better your chances for success.

Your insurance policy is in place to protect you from loss in the case of an accident, so you’re entitled to receive the benefits that you are entitled to as stated in the policy that you have.   You should feel comfortable that you will receive fair and equitable treatment from your insurance company in the case that you need to make a claim.   If you’re considering changing insurance providers, or want to get a better rate or switch your policy, looking for home insurance quotes or car insurance quotes online is the perfect solution to make sure that you’re protected for the best price.

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