How to make a Claim against an Insurance Company

How to make a Claim against an Insurance Company

This post «How to make a claim against an insurance company» was originally published on March 20, 2018 and has been updated as of March 30, 2022.

Insurance , like so many other sectors of activity, generate complaints and claims from its customers . The body in charge of ensuring that ultimately they respect us is the general directorate of insurance of the Ministry of Economy.

But, unlike commerce, the regulations that regulate financial institutions in general (banks, insurance companies, credit cooperatives, etc.), have chosen to create a free claim procedure and specific institutions to claim.

These institutions are different from those known in the trade ( consumer mediation and arbitration ). In this post we tell you how to claim from an insurer. Be careful, we are talking about claiming but not giving a part to the insurance .

Who can claim

The policyholder, the insured, the beneficiary or a third party who feels harmed. All of them have a period of 2 years from the date on which they became aware of the facts giving rise to the complaint or claim, to file a claim.

How to claim

Step One: Make Sure We're Right

The first procedure to file a complaint or claim against the insurance companies is to inform us well of our problem. For this we must consult the contract and discern if the problem comes from the insurance company or the mediator that mediates our policy (insurance agent or our insurance broker ).

If he does not manage to solve our problem or we made a direct contract with the company, we will have to go directly to the office. Or resort to the contact telephone number of the customer service department of the insurance company.

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Second step: formally address the company

If we think we are right, the second step is to formally address it in writing . In the mail we will have to put the details of what happened, our claim and attach the annexes that are necessary to provide.

You must address the letter to the company's customer service center or its customer ombudsman, and wait for it to rule (maximum 2 months from our claim).

The procedure will begin by presenting a document to which the company indicates, in which it will be stated:

a) Name, surnames, address and DNI of the interested party.

b) Reason for the complaint or claim, with a clear specification of the issues on which a statement is requested.

c) Office or offices, department or service where the events object of the complaint or claim took place.

d) That as claimants, we are not aware that the subject matter of the complaint or claim is being handled by another means (administrative, arbitral or judicial procedure).

e) Place, date and signature.

f) documentary evidence in our possession on which the complaint or claim is based.

How and to whom is this documentation presented?

The rule (*) says that before the customer service departments or before the customer ombudsman of the insurer, in any office open to the public of the entity, as well as in the e-mail address enabled for this purpose.

In fact, if the object of the claim has nothing to do with the powers of the customer ombudsman, he will refer it to customer service.

In any case, the company must acknowledge receipt in writing and record the date of presentation for the purposes of calculating the aforementioned two-month period.

As claimants, we are only obliged to present the claim once, and the insurer must provide copies of it to the departments involved.

If the claim is not clear in any aspect, the insurer will tell us, giving us a period of 10 days to provide any explanatory notes, after which the claim can be filed.

Third step: pronouncement of the insurer

In a maximum of two months, the customer service or the insurer's ombudsman will rule in favor or against.

You will have to do so in a motivated manner and with clear conclusions about the request made, based on the contractual clauses, the applicable transparency and customer protection regulations, as well as good practices and financial uses.

The company will have a maximum of 10 days to send the claimant this statement.

If it is in favor, its decision will be binding for the company, unless the claimant expressly withdraws his claim (the file would be archived).

If it is against us, we will not be obliged to accept the resolution of the service and, if we do not accept it, we will be able to exercise the appropriate administrative actions.

These consist of a recourse to the Commissioner for the Defense of the Insured and the Participant in Pension Plans of the General Directorate of Insurance and/or legal actions that we deem appropriate.

Fourth step: resort to the Commissioner for the defense of the insured of the insurer

In order to file a complaint or claim before the Commissioner for the Defense of the Insured and the Participant in Pension Plans, it is necessary to prove compliance with the following requirements:

Having previously formulated the claim in writing to the department or customer service.

Two months must have elapsed from the date of filing the complaint or claim without it having been resolved by the aforementioned department or service. Or the admission of the claim must have been denied (or having been admitted, the petition must have been dismissed).

Fifth step: resort to the Complaints Service of the General Directorate of Insurance

The penultimate resource in an insurance claim is to resort to the Claims Service of the General Directorate of Insurance and Pension Funds (DGSFP).

This body will rule on your case in a maximum of six months. The resolution issued may prove us right (or not). But, in a favorable case, it will not be mandatory for the claimed insurance company to comply. That is, it is not binding. But it could be the very powerful evidentiary document against the last resort: the courts of justice.

Sixth step: go to court

The last step in this chain of claims will be to resort to the courts of justice through a lawsuit.

Related regulations

The regulations that regulate claims to insurers and banks in Spain are:

Order ECO/734/2004, of March 11, on customer service departments and services and the customer ombudsman of financial institutions (BOE, No. 72 of March 24, 2004).

This rule also applies when you want to claim against a bank .

Complaints hotline

In the comments of this post you have several cases of claims against direct line, which sells cheap insurance that later turns out to be expensive. Contribute with your case and thus we make more consumers know in depth what they hire. Here we tell you about Elena's case with her home insurance and LD's 902 customer service telephone number.