An insurer can reject a claim where the policy genuinely does not cover the loss, but a refusal is not self-proving. Ask what clause, fact and evidence the insurer relies on, then test each part of that reasoning.
Insurance disputes are rarely decided by one sentence in the policy. The wording, what the insurer asked, what happened, the evidence and the reason given for the decision all matter. Keep those questions separate so the complaint stays testable.
Key points
- ICOBS requires insurers to handle claims promptly and fairly and not unreasonably reject a claim.
- A refusal based on no cover is different from a refusal based on an exclusion, misrepresentation, fraud, causation or lack of evidence.
- The insurer should be able to explain the relevant policy wording and the factual basis for applying it.
- If the complaint is unresolved after the firm process, an eligible consumer can normally ask FOS to decide what is fair and reasonable.
Diagnosis
First: what exactly has happened?
Start by identifying the actual dispute. Similar-looking insurance complaints can turn on very different rules.
| What happened? | What to check first |
|---|---|
| The insurer says the event is not covered | Identify the insured peril or benefit you rely on and the definition used in the policy. |
| The insurer relies on an exclusion | Check whether the exclusion actually applies to the cause of loss and whether it was properly presented. |
| The insurer says you gave wrong information | Move to the CIDRA / misrepresentation analysis rather than arguing only about the claim event. |
| The insurer says there is not enough evidence | Ask exactly what evidence is missing, why it is material and whether reasonable alternatives are available. |
| The insurer alleges fraud or exaggeration | Ask the insurer to identify the allegation and evidence; do not treat an ordinary coverage dispute as a fraud finding. |
Start with the exact reason for rejection
Ask for the decision in writing if you only have a call note or portal message. A useful refusal identifies the policy clause, the facts found, the evidence relied on and why those facts take the claim outside cover. If the response merely says "not covered" or "terms and conditions apply", the first complaint point is lack of reasons.
Coverage, exclusion and causation are different questions
A policy may cover a type of event but exclude a particular cause, circumstance or category of loss. Alternatively the insurer may accept that the event happened but dispute what caused the damage. Keep those questions separate. For example, "storm damage is covered" does not answer whether the roof damage was caused by a storm or by pre-existing deterioration.
The insurer still has to apply the policy fairly
ICOBS 8 says insurers must handle claims promptly and fairly, provide reasonable guidance, not unreasonably reject claims and settle promptly once terms are agreed. That does not rewrite the policy into broader cover, but it does mean the insurer should apply the contract and evidence reasonably rather than searching for a technical excuse after the event.
Significant or unusual exclusions deserve particular scrutiny
If the refusal depends on a limitation that is especially significant, surprising or inconsistent with how the cover was presented, look at how prominently it was disclosed before purchase. FOS can consider the policy wording, sales information and whether it is fair for the firm to rely on the term in the circumstances.
What if the insurer says wear and tear or gradual damage?
Those exclusions are common, especially in home insurance, but the label is not enough. Ask what expert evidence shows that the operative cause was gradual deterioration rather than an insured event. A loss can have several contributing causes, and the policy wording determines how they interact.
What if the claim was rejected after an investigation?
An investigator, loss adjuster or engineer may collect facts, but the insurer remains responsible for the claim decision. Ask for the material findings relied on. If a report contains assumptions, factual errors or an incomplete history, challenge those points specifically and provide contrary evidence.
What remedy can you realistically seek?
If the claim should have been accepted, the starting remedy is usually to put the consumer in the position the policy promised: repair, replacement, cash settlement or another contractual benefit. Additional direct financial loss caused by mishandling can sometimes be considered, and FOS may also award compensation for distress or inconvenience where appropriate.
What to say next
Write a short challenge that identifies: (1) the policy clause relied on; (2) the fact you say is wrong or incomplete; (3) the evidence that supports your position; and (4) the remedy you want. Ask the insurer to answer those points separately. This is more effective than repeating that the decision is "unfair" without identifying why.
Escalation
Make a formal complaint to the insurer or regulated intermediary first. For most insurance complaints the firm has up to eight weeks to send the required written response. If you reject the final response, or the response period expires, check FOS eligibility and the six-month referral deadline stated in a valid final response.
Who is responsible for the decision?
The insurer or underwriting firm named on the policy is normally responsible for the claim decision, even if a loss adjuster, engineer, repair network or claims administrator handled the day-to-day work. If the dispute is about how the policy was sold rather than how the claim was decided, a broker or intermediary may also be responsible for its own advice or representations.
If several firms are involved, ask each to state its role. Do not accept a circular chain where the broker blames the insurer, the insurer blames an adjuster and the adjuster says it only follows instructions. The complaint should be directed to the regulated firm responsible for the decision you are challenging.
What remedy is realistic?
If the refusal was wrong, the ordinary aim is to put you in the position the policy should have produced. That can mean reopening and paying the claim, arranging repairs, replacing property, reimbursing reasonable costs or reassessing the loss under the correct policy term.
If unreasonable claim handling caused additional financial loss, identify that separately. FOS can also consider compensation for distress and inconvenience where the firm has caused material trouble beyond the insured event itself. The complaint is stronger when the requested outcome is quantified and connected to the insurer's error.
Important exceptions and edge cases
Fraud is different from an ordinary coverage disagreement. A deliberately fabricated or exaggerated claim can have serious consequences, but an insurer should not use fraud language loosely simply because evidence is incomplete or the parties disagree about value. Ask the firm to identify exactly what conduct it alleges.
Older policies, commercial policies, group arrangements, Lloyd's market complaints and claims involving several insurers can follow additional rules or procedures. Always use the wording and regulatory framework that applied to the actual policy and date of loss.
Common insurer responses - and what they do not necessarily prove
| The insurer says | What to test |
|---|---|
| "The policy wording is clear." | Clear wording still has to apply to the facts. Ask the insurer to explain the factual step between the evidence and the clause. |
| "Our loss adjuster has made the decision." | The adjuster can investigate, but the regulated insurer remains responsible for its claim decision. |
| "There is no proof of the loss." | Ask what reasonable proof is required. Original receipts are useful but are not the only possible evidence of ownership or value. |
| "You accepted the terms when you bought the policy." | Acceptance does not answer whether the term was properly applied or whether the firm handled the claim fairly. |
Evidence worth keeping
Build the file around the issue the insurer actually has to decide. Preserve documents from the time of the claim rather than relying on memory later.
What to do
A practical next-step plan
- Get the refusal and relied-on clause in writing.
- Separate coverage, exclusion, causation and evidence issues.
- Correct factual errors and attach focused evidence.
- State the policy remedy you want and any additional loss claimed.
- Use the insurer complaint process and preserve the FOS deadline.
What happens after you make a formal complaint?
The insurer or other regulated firm should acknowledge and investigate the complaint under the FCA complaint rules. For most ordinary insurance complaints it should send the required written response within eight weeks. Keep the complaint separate from day-to-day claim chasing: the claim can continue progressing while the complaint tests the decision or handling.
If you receive a final response and remain dissatisfied, check Financial Ombudsman eligibility immediately. FOS normally requires referral within six months of the date on a valid final response. Continuing to argue with the insurer does not safely stop that external clock, so diary it even if the firm says it is willing to look again.
Official sources
Check the current source material.
- FCA Handbook: ICOBS 8 claims handling
- Financial Ombudsman Service: insurance complaints
- FCA: how to complain
Insurance rules, policy wording and Financial Ombudsman approaches can change. Check the live source and the policy wording for the relevant policy year before relying on a formal deadline, exclusion or remedy.