The Most Common Grounds for Complaint in 2021

Publication date: August 23, 2022

Targeted audiences

Claims adjuster Damage insurance agent Damage Insurance Broker

1. Negligence

This category includes grounds for complaint related to deadlines, communication of information, modes of operation (including client-record keeping), and professional practice that does not comply with established guidelines, standards, requirements and obligations.

Damage insurance agents and brokers	Claims adjusters
An insured contacts her broker to tell him that she finds the renewal premium for her home insurance contract to be rather steep. To lower the premium, the broker reduces the amount of insurance coverage on the building stipulated in her contract.	A fire occurs in a rental building owned by non-occupant co-insureds. The claims adjuster explains how the claims process will proceed, in particular with respect to demolition and construction work. However, he is extremely late in notifying them that they may be able to claim compensation for loss of rental income, as provided for in their contract.
Deficiency to be corrected? To ensure that the coverages continued to meet his client’s needs, as renewal time was approaching, the broker should have updated the insured’s file with her. In addition to acting negligently by making changes solely in order to reduce her insurance premium, the broker failed to properly advise the insured when he reduced the amount of coverage without receiving any request or consent to do so from his client	Deficiency to be corrected? It was only as the work drew to a close that he told the insureds about this coverage. As soon as he opened the file, the claims adjuster should have told them that their contract included coverage for loss of rental income and explained to them the conditions for application.

Damage insurance agents and brokers

Claims adjusters

An insured contacts her broker to tell him that she finds the renewal premium for her home insurance contract to be rather steep. To lower the premium, the broker reduces the amount of insurance coverage on the building stipulated in her contract.

A fire occurs in a rental building owned by non-occupant co-insureds. The claims adjuster explains how the claims process will proceed, in particular with respect to demolition and construction work. However, he is extremely late in notifying them that they may be able to claim compensation for loss of rental income, as provided for in their contract.

Deficiency to be corrected?

To ensure that the coverages continued to meet his client’s needs, as renewal time was approaching, the broker should have updated the insured’s file with her.

In addition to acting negligently by making changes solely in order to reduce her insurance premium, the broker failed to properly advise the insured when he reduced the amount of coverage without receiving any request or consent to do so from his client

Deficiency to be corrected?

It was only as the work drew to a close that he told the insureds about this coverage. As soon as he opened the file, the claims adjuster should have told them that their contract included coverage for loss of rental income and explained to them the conditions for application.

2. Failure to explain, inform and advise

This category includes grounds for complaint related to the obligations to inform and advise, to communicate with the client and maintain client relations, and to not mislead the client.

Damage insurance agents and brokers	Claims adjusters
In the wake of a fire, an insured realizes that the amount of coverage for additional living expenses provided for in his tenant’s insurance is insufficient. Before purchasing the contract, the agent advising him had never mentioned this coverage, nor did he describe it or explain the limits in the contract.	In the wake of water damage, a claims adjuster notifies the insured that the work will be covered, as long as she deals with a contractor who partners with the insurer. He also explains to her the nature and extent of the assignment of claim to the contractor. A few months later, with the work still not finished, the contractor has the insured sign a document stating that she is satisfied with the work. The insured thinks this is the assignment of claim. When the insured expresses dissatisfaction with the work, the claims adjuster tells her that unfortunately she signed a document stating the contrary.
Deficiency to be corrected? The advisory role of agents and brokers is an essential part of service delivery. The agent should have described the coverage proposed to the insured, and specified the nature of the coverage offered, its limits and exclusions of coverage, if any.	Deficiency to be corrected? From the outset, the adjuster should have told her that she would have to sign a document confirming her satisfaction once the work was finished, and given her a detailed explanation of its contents, meaning and what it entailed.

Damage insurance agents and brokers

Claims adjusters

In the wake of a fire, an insured realizes that the amount of coverage for additional living expenses provided for in his tenant’s insurance is insufficient.

Before purchasing the contract, the agent advising him had never mentioned this coverage, nor did he describe it or explain the limits in the contract.

In the wake of water damage, a claims adjuster notifies the insured that the work will be covered, as long as she deals with a contractor who partners with the insurer. He also explains to her the nature and extent of the assignment of claim to the contractor.

A few months later, with the work still not finished, the contractor has the insured sign a document stating that she is satisfied with the work. The insured thinks this is the assignment of claim.

When the insured expresses dissatisfaction with the work, the claims adjuster tells her that unfortunately she signed a document stating the contrary.

Deficiency to be corrected?

The advisory role of agents and brokers is an essential part of service delivery. The agent should have described the coverage proposed to the insured, and specified the nature of the coverage offered, its limits and exclusions of coverage, if any.

Deficiency to be corrected?

From the outset, the adjuster should have told her that she would have to sign a document confirming her satisfaction once the work was finished, and given her a detailed explanation of its contents, meaning and what it entailed.

3. Poorly carrying out the mandate

This category includes grounds for complaints related to the obligations to act promptly and honestly, as well as grounds related to reporting, collecting information and renewing contracts.

Damage insurance agents and brokers	Claims adjusters
A broker collects information from a new vehicle owner and submits a quote, which the client accepts. A subsequent verification in the “Fichier central des sinistres automobiles” (Automobile Claims Database) reveals information that would result in a higher premium than that quoted to client. The broker is unsuccessful in his attempts to reach the client. He therefore closes the file, and the contract is never issued. Three weeks later, having still not received his contract, the insured calls the broker, who realizes what has happened. He also notifies the client of the new premium for the contract. The insured feels that it is too high.	An insured reports the theft of tools and other property from his shed. The claims adjuster asks him to fill out a statement of loss. The adjuster receives the statement, files it away, and does nothing more. Two weeks go by. The insured follows up with the adjuster who confirms that he has received the statement of loss and presents a settlement offer to the client, which the client accepts. Three weeks later, the insured must once again follow up since he has still not received his cheque for the compensation he accepted.
Deficiency to be corrected? The broker should have followed up on the client’s instructions and given him the coverage requested. Being left uninsured can lead to grave consequences for an insured. The broker should have also made every effort to reach the insured and notify him of any changes to his file, in particular the cost of the insurance premium. PLEASE READ “HAVING TROUBLE REACHING A CLIENT?”	Deficiency to be corrected? The claims adjuster should have done the necessary follow-up and issued the payment as soon as the insured accepted the offer of settlement. All these delays could have been avoided if the adjuster had not dragged his feet in processing the file.

Damage insurance agents and brokers

Claims adjusters

A broker collects information from a new vehicle owner and submits a quote, which the client accepts.

A subsequent verification in the “Fichier central des sinistres automobiles” (Automobile Claims Database) reveals information that would result in a higher premium than that quoted to client. The broker is unsuccessful in his attempts to reach the client. He therefore closes the file, and the contract is never issued.

Three weeks later, having still not received his contract, the insured calls the broker, who realizes what has happened. He also notifies the client of the new premium for the contract. The insured feels that it is too high.

An insured reports the theft of tools and other property from his shed. The claims adjuster asks him to fill out a statement of loss.

The adjuster receives the statement, files it away, and does nothing more.

Two weeks go by. The insured follows up with the adjuster who confirms that he has received the statement of loss and presents a settlement offer to the client, which the client accepts.

Three weeks later, the insured must once again follow up since he has still not received his cheque for the compensation he accepted.

Deficiency to be corrected?

The broker should have followed up on the client’s instructions and given him the coverage requested. Being left uninsured can lead to grave consequences for an insured.

The broker should have also made every effort to reach the insured and notify him of any changes to his file, in particular the cost of the insurance premium.

PLEASE READ “HAVING TROUBLE REACHING A CLIENT?”

Deficiency to be corrected?

The claims adjuster should have done the necessary follow-up and issued the payment as soon as the insured accepted the offer of settlement.

All these delays could have been avoided if the adjuster had not dragged his feet in processing the file.

4. Attitude (lack of moderation and objectivity)

This category includes grounds for complaint related to objectivity, the professional’s hard and soft skills, as well as the core values of respect, transparency, integrity, and professionalism.

Damage insurance agents and brokers	Claims adjusters
An insured is shopping for an insurance quote and talks to an agent. When she mentions the name of her current brokerage firm, the agent tells her that she is paying extra fees to do business with a broker and makes derogatory comments about the business practices of the firm in question.	An insured suffers water damage. The claims adjuster tells him that an estimator will be come by shortly to prepare a quote for the damages. The insured tells him that he wants to hire a contractor he knows to do the work. Since the adjuster is leaving on vacation, he mentions to the insured that he might only receive the quote in two weeks. However, the insured does not want to wait that long to submit his contractor’s quote and start the work. Irritated, the adjuster asks the insured “if he wants him to cancel his vacation.”
Deficiency to be corrected? The agent should have refrained from making such comments. The conduct of an agent or broker must be characterized by objectivity, discretion, moderation and dignity at all times.	Deficiency to be corrected? Both the question and tone of the claims adjuster were inappropriate. The adjuster should have been reassuring. He could have explained to the insured that a colleague would take care of the file during his absence. Adjusters must adopt a neutral tone, even when speaking to someone who is upset.

Damage insurance agents and brokers

Claims adjusters

An insured is shopping for an insurance quote and talks to an agent. When she mentions the name of her current brokerage firm, the agent tells her that she is paying extra fees to do business with a broker and makes derogatory comments about the business practices of the firm in question.

An insured suffers water damage. The claims adjuster tells him that an estimator will be come by shortly to prepare a quote for the damages. The insured tells him that he wants to hire a contractor he knows to do the work.

Since the adjuster is leaving on vacation, he mentions to the insured that he might only receive the quote in two weeks. However, the insured does not want to wait that long to submit his contractor’s quote and start the work. Irritated, the adjuster asks the insured “if he wants him to cancel his vacation.”

Deficiency to be corrected?

The agent should have refrained from making such comments. The conduct of an agent or broker must be characterized by objectivity, discretion, moderation and dignity at all times.

Deficiency to be corrected?

Both the question and tone of the claims adjuster were inappropriate. The adjuster should have been reassuring. He could have explained to the insured that a colleague would take care of the file during his absence.

Adjusters must adopt a neutral tone, even when speaking to someone who is upset.

5. Personal information

This category includes grounds for complaint related to the disclosure, or the illegal or prohibited communication of personal information.

Damage insurance agents and brokers	Claims adjusters
An insured informs his agent that he is moving to Ontario and will be renting out his house in Quebec. The agent tells him that under the circumstances he can no longer insure the residence in Quebec but asks the insured for permission to give his phone number to his cousin, who is a damage insurance broker. The insured agrees. However, when the agent gives his cousin the insured’s phone number, he also gives him all the information in the client’s file to help the broker fill out the application and request quotes.	An insured makes a claim for damages to his vehicle. The claims adjuster advises him that the insurer has declared the vehicle a “total loss.” The insured’s daughter takes charge of his file and asks to receive an email copy of the estimated damages to her father’s vehicle. The claims adjuster sends her a copy of the estimate and an offer of settlement.
Deficiency to be corrected? As was agreed upon with the insured, the agent should only have given his phone number to the broker so the broker could then contact the insured and conduct the needs analysis. He could not communicate the insured’s personal information to his cousin without first obtaining his client’s consent.	Deficiency to be corrected? Cc’ing the insured in the email does not mean he gave his consent. The claims adjuster should have obtained the insured’s authorisation to deal with a third party, in this case, the insured’s daughter. Without the insured’s authorisation or power of attorney, the adjuster was disclosing confidential information without having the right to do so.

Damage insurance agents and brokers

Claims adjusters

An insured informs his agent that he is moving to Ontario and will be renting out his house in Quebec. The agent tells him that under the circumstances he can no longer insure the residence in Quebec but asks the insured for permission to give his phone number to his cousin, who is a damage insurance broker. The insured agrees.

However, when the agent gives his cousin the insured’s phone number, he also gives him all the information in the client’s file to help the broker fill out the application and request quotes.

An insured makes a claim for damages to his vehicle. The claims adjuster advises him that the insurer has declared the vehicle a “total loss.”

The insured’s daughter takes charge of his file and asks to receive an email copy of the estimated damages to her father’s vehicle. The claims adjuster sends her a copy of the estimate and an offer of settlement.

Deficiency to be corrected?

As was agreed upon with the insured, the agent should only have given his phone number to the broker so the broker could then contact the insured and conduct the needs analysis. He could not communicate the insured’s personal information to his cousin without first obtaining his client’s consent.

Deficiency to be corrected?

Cc’ing the insured in the email does not mean he gave his consent. The claims adjuster should have obtained the insured’s authorisation to deal with a third party, in this case, the insured’s daughter. Without the insured’s authorisation or power of attorney, the adjuster was disclosing confidential information without having the right to do so.