When your claim is denied after an insurer’s damage investigation, it is a frustrating experience. You have suffered damage, you filed your claim properly and the insurer carried out an investigation. Then you receive notice that your claim is denied. The reasons can range from suspected fraud to failing to meet the policy terms. But a denial after a damage investigation is not always justified. In this article you will read why insurers deny claims, what rights you have and how to challenge the denial.
Why does an insurer deny your claim after a damage investigation?
An insurer may decide to deny your claim after a damage investigation for various reasons. It is important to know the exact reason, because that determines what defenses you have and how best to respond.
Suspected fraud
The most serious reason for denial is suspicion of fraud. If the damage investigation reveals indications that the damage did not occur as you stated, that the damage has been exaggerated or that the damaging event did not take place, the insurer can deny your claim on the grounds of fraud. An accusation of fraud is often accompanied by a registration in the EVR (Elektronisch Verzekeringsregister) and the cancellation of your policy (royement).
Breach of the policy terms
A common reason for denial is that the damage is not covered under the policy terms. This can mean that the type of damage is excluded, that the damage falls below the deductible, or that you did not comply with certain conditions, such as taking sufficient security measures. The insurer must clearly explain which policy term applies and why the damage is not covered.
Breach of the duty to disclose
If the investigation shows that you did not provide relevant information or provided incorrect information when taking out the insurance, the insurer can deny your claim on the grounds of non-disclosure. The insurer must, however, demonstrate that the withheld information was relevant to the acceptance decision.
Insufficient cooperation with the investigation
Your policy terms generally contain an obligation to cooperate. If you have not sufficiently cooperated with the damage investigation, the insurer may cite this as a reason to deny your claim. The insurer must be able to show that your lack of cooperation harmed its interests.
Your rights after denial of your claim
If your claim is denied after a damage investigation, you have a number of important rights that enable you to challenge the denial.
Right to a clear motivation
The insurer is obliged to provide you with a written and clear motivation explaining why your claim is denied. The motivation must be specific and refer to the relevant policy terms or statutory provisions. A vague or unmotivated denial can be contested.
Right to the investigation file
Pursuant to the AVG (Algemene Verordening Gegevensbescherming, the EU General Data Protection Regulation – GDPR) you have the right to access all personal data collected in the context of the damage investigation. This includes the investigation report, interview notes, expert reports and any photo or video material. By requesting access to the file you can check whether the investigation was conducted correctly and whether the insurer’s conclusions are justified.
Right to a second opinion
If the denial is based on an expert report, you have the right to engage your own expert for a counter-expertise (contra-expertise). The outcome of a counter-expertise can rebut the conclusions of the expert engaged by the insurer and is an important piece of evidence in any objection procedure.
The role of the counter-expertise
If the denial of your claim after a damage investigation is based on an expert report, a counter-expertise can be of great importance for your defense. An independent expert engaged by you assesses the same facts as the insurer’s expert, but may reach different conclusions. The difference in findings may show that the insurer’s conclusions are not conclusive and that there is room for another interpretation of the facts. When choosing a counter-expert, it is important to select an expert who has the appropriate qualifications and experience in the relevant field. A well-substantiated counter-expert report can make the difference in a procedure before the Kifid (Klachteninstituut Financiële Dienstverlening) or the court. The costs of a counter-expertise can be recovered from the insurer if the procedure is successful.
Time limits when challenging a denial
When challenging a denied claim after a damage investigation it is crucial to pay attention to the applicable time limits. The limitation period for claims arising from insurance contracts is in principle three years. After this period has expired you lose the right to challenge the denial. It is therefore advisable to act as soon as possible after receiving the denial letter. For a complaint to Kifid its own deadlines apply. Kifid states that you must in principle submit your complaint within one year after reporting the complaint to your financial service provider, or within three months after the denial letter. The exact criteria are set out in the applicable Kifid regulations (Kifid-reglement). It is advisable to keep a close eye on these time limits and not to wait unnecessarily long before seeking
legal assistance.
Steps to challenge the denial
If you disagree with the denial of your claim after the damage investigation, you can take the following steps.
Step 1: Analyze the grounds for denial
Read the denial letter carefully and determine on what grounds the insurer denied your claim. Check whether the grounds cited correspond with the policy terms and with the facts as you know them. Note all points on which you disagree with the insurer.
Step 2: Request the investigation file
Submit a request for access to the insurer to receive the complete investigation file.
Check whether the investigation was conducted correctly, whether the facts are accurate and whether the conclusions logically
follow from the findings. Also pay attention to any procedural errors in the investigation.
Step 3: Submit a written objection
Write a well-founded objection in which you explain why you disagree with the denial. Refer to the relevant policy terms, statutory provisions and pieces of evidence that support your position. A well-substantiated objection can persuade the insurer to revise its position.
Step 4: Engage a lawyer
If the insurer maintains its position, it is advisable to engage a specialized lawyer. A lawyer can assess the legal viability of your case and support you in a procedure before the Kifid or the court. In insurance disputes, legal assistance often makes the difference between a denial that stands and a successful revision.
Complaint to Kifid
The Klachteninstituut Financiële Dienstverlening is an accessible body where you can take complaints about your insurer. Kifid handles disputes about denied claims and can issue a binding decision. The Kifid procedure is usually faster and cheaper than going to court. A lawyer can also assist you in a Kifid procedure to represent your interests as effectively as possible.
Proceedings in court
If Kifid is not competent or if you wish a judicial ruling, you can start proceedings at the court. The judge assesses whether the insurer rightly denied your claim and whether the damage investigation was properly conducted. In court you have more possibilities to present evidence, hear witnesses and engage experts. A court judgment is binding on both parties.
Common mistakes when challenging a denial
When challenging a denied claim after a damage investigation, mistakes are frequently made that reduce the chances of success. The most common mistake is waiting too long to take action. The longer you wait, the harder it becomes to collect evidence and the greater the risk that deadlines will expire. Another frequent mistake is challenging the denial without having inspected the investigation file. Without knowledge of the findings of the investigation you cannot mount an effective defense. In addition, it is not advisable to engage in correspondence with the insurer about complex legal issues without legal assistance, because statements you make can later be used against you.
The importance of your own file
One of the most effective steps you can take when your claim is denied after a damage investigation is to build your own file. This file contains all documents relating to the damage and the handling of your claim: the policy terms, the damage report, correspondence with the insurer, the expert report, photos of the damage, witness statements and any medical reports. A well-prepared file enables your lawyer to quickly assess whether the denial of your claim is legally sustainable. It also helps you to clearly formulate and substantiate your own view of the facts. Many insureds underestimate the importance of good file-keeping, while in practice this often makes the difference between a successful and an unsuccessful objection procedure.
The burden of proof in a denied claim
The question of who must prove what plays a central role in disputes about denied claims. In principle, the insured bears the burden of proof that a covered event occurred. The insurer bears the burden of proof for facts that support reliance on an exclusion. If the insurer denies your claim on the basis of an exclusion in the policy terms, the insurer must demonstrate that the exclusion applies. This allocation of the burden of proof can work in your favor if the insurer lacks sufficient evidence for its position.
Subsidized legal aid
Challenging a denied claim does not have to be unaffordable. If your income is limited, you may be eligible for subsidized legal aid via the Raad voor Rechtsbijstand (Legal Aid Board). A toevoeging (legal aid grant) ensures that the government pays the majority of the lawyer’s fees and you only owe a limited personal contribution. In this way professional legal assistance is accessible to everyone.
The difference between an internal and external complaints procedure
With a denied claim after a damage investigation you have both internal and external options to lodge an objection. The internal complaints procedure means that you address your objection to the insurer’s own complaints department. Many insurers have an internal complaints committee that will re-examine your objection. It is wise to first go through the internal complaints procedure before turning to an external body, because this may be a requirement for filing a complaint with Kifid. If the internal complaints procedure does not lead to a satisfactory result, you can move on to an external procedure with Kifid or the court. The choice between Kifid and the court depends on factors such as the financial stake of the case, the complexity of the dispute and your personal preference. A lawyer can advise you which route is most promising and efficient in your situation.
Have your denied claim assessed
A denial after a damage investigation is not necessarily the end of the road. Many denials prove to be unsustainable upon closer examination, for example because the investigation was flawed, the policy terms should be interpreted differently or the insurer was not entitled to refuse payment. A specialized lawyer can assess your case and advise you on the most promising strategy. Has your claim been denied after a damage investigation and do you disagree? Contact us for a non-binding assessment of your case. We analyze the grounds for denial, review the investigation file and advise you on the possibilities to still realize your entitlement to payment. Do not wait too long, because acting in time increases your chances.
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