Getting your Insurance Claim Settled: Know your Options

There are a variety of steps you can take to resolve an outstanding insurance claim with your insurance provider. When issues, concerns, and disagreements arise, the following options are available.

Option 1: Dealing with Your Insurer

  • Contact your adjuster, review what is delaying the settlement of the claim, and come to an agreement on a plan to get the claim back on track.

  • If settlement of the claim cannot be agreed upon with the adjuster, contact the adjuster’s claims supervisor or manager.

  • If the claim is still not settled, contact your insurer’s complaint liaison officer / ombudsperson.
    In Alberta, all insurers are required to have an ombudsperson. Please refer to the following list,
    which is maintained by the Superintendent of Insurance:

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Option 2: The Dispute Resolution Process

When you cannot reach an agreement about the value of the insured property, the value of the property saved, the nature and extent of the repairs or replacements required, or the amount of the loss or damage, those questions must be determined using the Dispute Resolution Process set out in section 519 of the Insurance Act (Act).

The dispute resolution process must be used in settling the amount of a loss with your own insurer. Your insurer must send you a copy of section 519 of the Act within ten days of determining that there is a dispute in respect to the amount of a loss.

Alternatively, as an insured, you can initiate the dispute resolution process in respect to the amount of a loss at any time, through the following process:

  • You must file a proof of loss form with the insurer and make a written request to start the dispute resolution process. A proof of loss form is available from your adjuster.

  • Within seven days, you and your insurer must each appoint, at your own cost, someone to represent your interests. Neither party can represent themselves, and neither can appoint employees.

  • There is no requirement to appoint an appraiser to represent you. You may appoint anyone of your own choosing, although it is highly recommended you appoint a representative with expertise in the subject matter being disputed.

  • If the two representatives cannot agree on the amount of the loss, they will appoint an umpire to assist in establishing the amount of the loss. If the representatives cannot agree on an umpire, they can apply to Alberta’s Superintendent of Insurance to select one. See the documents below:

  • The umpire will issue a written decision based on information provided by the representatives.

  • The outcome of the dispute resolution process is final and binding for both the insured and the insurer on the issue of the amount of the loss.

  • It is important to note that the dispute resolution cannot be used to resolve contractual disagreements, such as whether there is coverage under the policy.  The interpretation of what is covered by your policy is a matter for the courts to decide.

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Option 3: Contact independent Insurance OmbudService

There are independent organizations that help consumers resolve disputes or concerns with their insurance company.  These services are free of charge, and help address consumer concerns about claims, interpretation of policy coverage, and policy processing and handling. They will mediate between insureds and insurers, but do not have the ability to order settlement of a claim or provide a legal opinion about policy coverage.

  1. For general insurance, such as home, automobile and commercial insurance, contact the General Insurance OmbudService:
    Call toll-free: 1-877-225-0446

  2. For travel, life, accident and sickness, and other private health insurance, contact the OmbudService for Health and Life Insurance.
    Call toll-free: 1-888-295-8112

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Option 4: Legal Advice

In instances where settlement cannot be achieved through the above listed options, it may be beneficial to review the matter with legal counsel in order to best protect your own interests.

For information on finding a lawyer, contact the Law Society of Alberta.

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Tips for Resolving a Complaint

(Source:  Canadian Council of Insurance Regulators)

If you think there's a problem, ask for an explanation as soon as possible.

  • Often, problems arise due to misunderstanding or miscommunication between individuals. If addressed early, many problems can easily get sorted out. However, if you are not satisfied with the response you receive make a formal complaint.

Be clear about the problem and what you would like to see happen in the future.

  • A formal complaint often requires that you make a complaint in writing. You need to identify the problem, state why you think it's a problem and set out what you would like to happen. Put down the facts in a logical order and provide relevant information and copies of documents. Avoid unnecessary detail and repetition. Avoid bringing new issues forward while the complaint is going through the process. Often this confuses matters and results in unnecessary delays.

Ask for information when necessary.

  • Know your rights about filing a complaint. Keep in mind that some companies are required to have a complaint process that includes providing information on how to make a complaint, how long the process will take and the next steps if the complaint remains unresolved.

Keep a complaint file.

  • Make copies of all correspondence and official documents you send to the company. Always send copies of official documents and keep the original for your file.

Keep records of conversations.

  • If you phone a company or attend a meeting, keep a record of the date, the name of the person you spoke to and the main issues raised by both of you. If there is an action expected following a conversation, send a confirmation letter to the company. Be specific about the agreed action and the timelines.

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Page last updated:  August 28, 2018