How to Appeal Rejected Insurance Claims - A Legal Guide

It can be difficult and frustrating to deal with a denied insurance claim. However, understanding the reasons for claim rejections and how to appeal them can significantly improve your chance of success. Our legal team will help you understand the reasons for insurance claim denials and how to challenge a disputed claim.

Thankfully, Aussie Injury Lawyer’s team of skilled insurance litigation lawyers provides advice on a 100% No Win, No Fee basis. Contact us immediately to learn your rights and how we can help when an insurer refuses to payout.

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Rejected Insurance Claim?

When an Australian insurance company denies your insurance claim or TPD claim, there is no need to panic. You do not need to accept their decision. There are options to challenge your insurer’s assessment and reverse their judgement so you can access your entitlements.

Regardless of the kind of insurance claim that has been rejected, there are options to appeal, including:

Why choose Aussie Injury Lawyers

Rejected or Denied Insurance & TPD Claims

99% Insurance Claims Success Rate

At Aussie Injury Lawyers, we win 99% of our insurance claims. Due to our many years of legal experience in these types of matters, most of our claims succeed without needing to be litigated. Should your insurer deny your entitlements in the first instance, we would argue your case on your behalf and seek to reverse their decision without litigation (which can be costly, stressful, and not consistently successful).

All insurers and superannuation funds have a formal internal dispute resolution process that often requires additional evidence. Additionally, there are time limits for superannuation funds and insurers to respond to your appeal, so you could get a fast reply.

Common reasons for a Rejected Insurance Claim

A rejected insurance claim is often a significant financial burden, especially if you feel your insurance policy should cover your situation. The first step towards successfully appealing a rejected claim is understanding the most common reasons for refusal.

  • You are still capable of working.
  • Not enough medical evidence
  • You could be employed in another occupation
  • Not meeting insurance policy conditions
  • Suspicion of fraud
  • You haven’t yet reached “maximum medical improvement.”
  • Failing to disclose information

If you are unfortunate to have your insurance claim denied, chat with one of our experienced insurance lawyers. They will find the best legal strategy for your case. Call now for free advice at 1300 873 252

The primary reason for a rejected insurance claim in Australia is lack of evidence. For your case to be successful, you must present the insurer with strong evidence that you satisfy the terms of your policy. These documents will show that you have a valid claim and often include the following:

  • Eyewitness accounts
  • Photographs and videos
  • Police reports
  • Medical records
  • Repair estimates
  • Documentation of expenses
  • Insurance policy documents
  • Financial records

Another common reason for rejected claims in Australia is failing to disclose complete and accurate information. Complete transparency during the insurance claim process is paramount, enabling insurers to gauge the risk precisely and set suitable coverage and premiums. You can face severe consequences for nondisclosure or misrepresentation, like cancellation of your policy or claim rejection.

When lodging an insurance claim, it is of utmost importance to provide the insurer with all the required details, such as your:

  • Claim history
  • Incidents related to the claim
  • Any personal data or records they might need to make a decision

Claim disputes often arise from failure to meet policy conditions or exclusion clauses. Fortunately, the Insurance Contracts Act 1984 (Cth) provides the legal framework for insurance contracts in Australia, including remedies when an insurer refuses to pay out a claim due to an act or omission after insurance contracts are signed.

Hence, you can reduce the chance of a rejected insurance claim by examining your insurance policy until you understand the clauses determining whether you qualify for a payout.

A couple discussing a rejected insurance claim form with a lawyer

Time Limits for Challenging Denied Insurance Claims

If you are disputing the outcome of a TPD, Income Protection or other type of insurance claim, time limits may apply. So please immediately speak with one of our legal team for free initial advice. Call 1300 873 252

How Aussie Injury Lawyers Can Help

Our experienced insurance claim dispute lawyers will:

  • Let you know if you have a valid case
  • Lodge a dispute with your Super fund/insurer
  • If you don’t achieve a settlement, possible litigation


Contact us now for a free case assessment

About the Internal Dispute Resolution (IDR) Process

The Internal Dispute Resolution process is the first step in appealing a denied claim. It is a formal procedure that includes the following steps:

  1. The insurer reviews the decision within 45 days.
  2. The person claiming can present their case and challenge the insurer’s decision.
  3. Your insurance litigation lawyer will act as your advocate during the IDR process, giving you expert advice and support.

The insurer will typically need more details or evidence before reevaluating the claim. Then, if the insurer doesn’t reverse their decision, they must explain why.

To start an IDR complaint, you contact the insurer with your details and follow their guidelines for submitting a complaint. Typically, you’ll need to provide:

  • Claim information
  • A timeline of events
  • Copies of relevant policy documents
  • Any other supporting documents related to the complaint.

Please keep copies of all correspondence and documents related to your case. If the IDR process doesn’t satisfactorily resolve the dispute, you can escalate the complaint to an external dispute resolution scheme, such as the Australian Financial Complaints Authority (AFCA), or seek legal advice.

Timelines and deadlines for IDR complaints may vary, but insurers typically must respond within 30-45 days. In some cases, the timeframe for an IDR complaint response can be extended under specific conditions, as specified in RG 271.

There can be consequences if the insurer doesn’t respond within the stipulated timeline, such as:

  1. The insurer has to pay the claim
  2. Penalties or fines
  3. Further complaints, disputes or litigation.
Australian financial complaints authority logo

External Dispute Resolution: The Australian Financial Complaints Authority (AFCA)

If the IDR process fails to resolve your dispute, the Australian Financial Complaints Authority (AFCA) offers external dispute resolution services for insurance claim disputes.

Before lodging a complaint with AFCA, you should attempt to resolve the issue directly with your superannuation fund or insurer. If you cannot resolve the dispute, you can file an AFCA complaint. Australian financial complaint authority determinations are binding, and if you accept their decision, the super fund or insurer must comply.

To file an AFCA complaint, you must complete a complaint form and provide the necessary documentation, including:

  • The name of the financial institution or superannuation fund that your complaint is against
  • Correspondence regarding the disputed case
  • Information and documents requested by AFCA
  • Any additional information or documents relevant to your denied compensation case should accompany the complaint form.

Relevant documents to include when filing an AFCA complaint can consist of:

  • Product Disclosure Statement (PDS)
  • Policy schedule
  • File notes
  • Correspondence between you and the other party

Accurate and complete documentation will increase your chance of a successful AFCA complaint and help facilitate the external dispute resolution process.

AFCA’s decision-making process involves:

  1. Reviewing the case
  2. Considering both parties’ arguments
  3. Making a final determination.

They consider factors such as:

  • The cause of the loss
  • Why the complainant disagrees with the initial decision
  • The value and complexity of the complaint
  • And whether the decision is fair in all cases.

To ensure both parties’ arguments are heard, AFCA follows these steps:

  1. Shares all expert evidence submitted with the other party
  2. Closely examine the provided proof when making a decision
  3. Asks the parties to explain the different claims in the complaint to narrow down the exact issues.

If the complaint can’t be resolved between the parties, AFCA will decide the best outcome and can provide compensation for losses suffered.

Legal Action and Litigation (Going to Court)

Legal action may be necessary if an IDR complaint and AFCA processes fail to resolve the dispute. Aussie Injury Lawyers rarely litigate an insurance claim in court, and we wouldn’t take action unless you instructed us to do so. Time limits for court claims also apply.

It is possible to lodge a court case for a rejected insurance claim against solely your insurer or your insurer and superannuation fund. Procedures for litigating in court vary from State to State and for different jurisdictions. Here is how the process works typically:

  1. A proceeding (statement of claim) is lodged with the court
  2. Your super fund/insurer lodges a response
  3. Disclosure – both parties exchange documents
  4. Usually, mediation will occur
  5. If mediation fails, the matter proceeds to court.

Litigation can take a significant amount of time and be stressful and expensive. However, it can force your insurer to seriously consider your case. Unfortunately, there is no guarantee you will win. But if your litigation succeeds, you may also be able to claim additional damages.

Why Hire An Insurance Lawyer?

It can be challenging to reverse a denied insurance claim. That’s because insurance companies seek to protect their profits. Thankfully, specialist insurance lawyers (like Aussie Injury Lawyers ) regularly negotiate with all the leading Australian insurers. On a 100% no win, no fee basis, we help with the following:

  • Experienced legal advice for insurance policies
  • Court representation when required
  • Expert guidance with the IDR and AFCA processes
  • Expertise in insurance law for strategic advice
  • Maximising the value of your claim

Hiring an insurance lawyer is a time and cost-effective decision in the long term, increasing your chance of a successful outcome. It’s free to start your case, and you pay nothing until we win your claim – Call Now 1300 873 252

Rejected Insurance Claim FAQs

If your claim is rejected, you can lodge a dispute with the insurer using their internal dispute resolution process or contact an insurance claim lawyer for help. If you still can’t achieve your desired outcome, you can take legal action or pursue other outside options.

In Australia, insurers typically deny between 10% and 20% of claims, although denial rates vary depending on the type of insurance cover and claim.

Insurance claims can be denied for various reasons, but most are rejected because of:

  • A policy exclusion
  • Not meeting or complying with the conditions of the policy
  • Or Non-disclosure of a pre-existing condition

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Meet Your Legal Team

Hardworking and straight talking, our experienced superannuation and insurance legal team is dedicated to delivering results for you. We understand how challenging life can be when things go wrong and we are here to help you get back to normal. The expert team at Aussie Injury Lawyers is led by Kerry Splatt, an Accredited Specialist in Personal Injuries law. His expertise together with over 100 years of combined legal experience is your guarantee of success. Reach out. Let us show you how we can assist you and your loved ones when the unexpected happens.

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