Deciding

General insurance disputes may be referred to a Panel or to an Ombudsman for a Determination

It is of course, in the best interests of the parties to try and find a resolution of a dispute without the need to proceed to a Determination by FOS. However, in some instances, disputes will need to progress to a final Determination by FOS. In the Operational Guidelines (OGs) we have provided information about the categories of general insurance disputes (other than disputes lodged against general insurance brokers) that will usually be dealt with by a FOS Panel if a matter does progress to a Determination. Here we also set out some additional information about which disputes might go to an Ombudsman for a Determination.

Panel

In the OGs, we said that the following categories of dispute will usually be dealt with by a FOS Panel where, in the opinion of the Chief Ombudsman or their delegate, the interests of the parties and the scheme require the disputes to be dealt with by the Panel. This includes:

  • all medical indemnity disputes
  • strata title insurance and small business insurance disputes (other than disputes lodged against insurance brokers)
  • disputes relating to claims arising from floods, storms, landslide, and other natural disaster events
  • disputes raising complex factual questions about medical, engineering, alcohol related, occupancy or earth movement matters
  • disputes where non disclosure in relation to a General Insurance Policy has been alleged and that might involve complex underwriting issues or insurance practice issues
  • disputes raising complex and/or important issues involving relevant legislation
  • disputes involving important issues with respect to the General Insurance Code of Practice and/or the need for guidance as to good insurance practice
  • disputes raising complex and /or important issues involving the Insurance Contracts Act 1984, and
  • disputes that involve similar circumstances to other disputes where a number of the disputes could be referred to a Panel to provide guidance for future Determinations.

Ombudsman

Disputes that do not fall into these categories will usually be considered by an Ombudsman. In the OGs, we specifically identified that general insurance disputes that involve an FSP alleging fraud by an applicant will be dealt with by an Ombudsman.


In addition, an Ombudsman will make the Determination for general insurance disputes where:

  • within 30 days of receiving the Recommendation, the financial services provider (FSP) has not accepted the Recommendation (paragraph 8.5 of the TOR)
  • within 30 days of receiving the Recommendation either party to the dispute
    • requests FOS to proceed to a Determination (paragraph 8.5 of the TOR), or
  • the dispute has been expedited to an Ombudsman (paragraph 8.6 of the TOR).

For more information about matters relevant to how a Determination is reached including the provision of information by the parties, interviews where a general insurance dispute involves a fraud allegation etc, see the commentary in the OGs on paragraphs 7 and 8 of the TOR.