Case Studies

CASE 1

Correcting a Misrepresentation

Synopsis of Complaint:

Consumer’s son borrowed the family vehicle and was involved in an accident. The consumer put in a claim, which was denied due to misrepresentation. Consumer contacted GIO for assistance after receiving a final position letter from his insurer maintaining the decision to deny his claim.

The insurer had determined that the consumer had not advised that his son was fully licensed, preventing the insurer to properly assess and rate the risk. The misrepresentation also resulted in the consumer receiving a notice of policy cancellation.

The consumer explained that he disclosed the driving status of his son to his agent but unfortunately there was nothing noted in the agent’s file regarding this. The agent had since left the company.

Review by GIO:

The Consumer Service Officer (CSO) handling the file asked the consumer to review all of his records (emails, text) to see if there was anything recorded in writing. The consumer had not thought to look for this information and was not sure he would find anything as many months had gone by.
A few days later the consumer shared an e-mail with the CSO showing that his agent was aware of his son’s license status.

Resolution:

The CSO contacted the company Ombudsman and shared the new information. The insurer agreed to postpone the cancellation of the policy until the matter was further reviewed. In the end, the insurer was satisfied that there was a miscommunication and honored the consumer’s claim and maintained the policy in force.

CASE 2

Clarifying Coverage

Synopsis of Complaint:

Insured relied on a quote in which she provided information regarding her upcoming trip of a lifetime. Deposits for air, a cruise and half the cost of her Wedding Planner were paid when she contacted a travel agent regarding coverage.

Fast forward and, like many, her dream trip was cancelled due to Covid-19. She received her deposits back for her airfare and cruise however upon submitting a claim for the wedding planner costs, her claim was denied. The Insurer advised that this was not a covered expenditure.

Review by GIO:

CSO brought forth reasonable evidence that the insured had reason to rely upon the initial call for a quote that coverage was in place for her wedding planner costs. Additionally, within the insured’s window to review the policy, definitions within the contract would not indicate these expenditures were not covered.

Resolution:

The claim was paid. The couple were then able to live “happily ever after!” 

CASE 3

Claim Denial Maintained

Synopsis of COMPLAINt:

Insured purchased a new mountain bike. Upon stopping on his drive home, he noticed his bike was no longer in the car rack. He contacted the police and filed a report.
Looking for protection security coverage off his credit card for newly acquired items, he reported the claim to his Insurance provider.

The claim was denied based on his report to the police that the bike had fallen off while driving. With no bike, the insurer was unable to assess damages.

The Insured approached the GIO for an independent review. He stated his bike could have been stolen as the bike rack straps were slashed.

Review by GIO:

GIO determined that the bike carrier honored a warranty claim of failed straps and provided a replacement carrier. There was insufficient evidence to support theft of bike and it was confirmed with the insured that the policy did not cover lost items.

Resolution:

Claim denial maintained. 

CASE 4

Clarifying Coverage

Synopsis of COMPLAINT:

There was an auto collision and the issue in dispute was reimbursement for the total cost of the tow expenses and rental expenses.

The consumer had his vehicle towed 3 times to accommodate removal from the accident scene to the collision reporting center and then to a body shop. The insured did not advise the insurer ahead of time of the 3 tows and proceeded to forward a bill for the cost of 3 tows for a total of $1,211.50. The insurer felt the cost was excessive and felt they could have negotiated a better price. They paid $1,011.50 based on what they felt they would have paid if given the opportunity to negotiate the cost. This left the consumer out of pocket $200.00.

The insurer has a program where they offer the policyholder $20 per day if they choose not to take a rental vehicle. The consumer initially took a rental but ultimately decided he did not need the rental so returned it and requested reimbursement for the remaining time he was entitled to the rental. The insurer refused to pay this amount as he had taken a rental, so the offer was no longer available since he did not choose it from the start. The amount requested was $140.00.

Review by GIO:

In the informal conciliation process CSO spoke to the insurer, who provided a detailed letter explaining their program and process. They refused to change their initial stance and the file prepared to move to mediation.

Resolution:

During preparation for mediation, the insurer spoke with its claims department and ultimately decided to pay the outstanding amounts to the consumer. The rental was paid as the adjuster did not advise the consumer at the outset that he could not change his selection once it was made.

CASE 5

Clarifying Policy Terms

Synopsis of COMPLAINT:

The client suffered water damage caused by a ruptured service line pipe. The insurer had denied the claim based on the fact that the cause of the water damage was a ruptured service line, and that the plumbing system was outside the dwelling.

Review by GIO:

Upon review it was determined that in their policy, under the Tear Out section, it was not mentioned that the plumbing system had to be inside the dwelling for the cost of the tear out to be covered.

Resolution:

The insurer reviewed their position and decided to settle with the client. 

 

CASE 6

Clarifying Policy Terms ​

Synopsis of COMPLAINT:

Claim made for a broken security camera system for which he has “equipment breakdown insurance” under a commercial policy. Upon reporting the loss, he was told he has a $1000 deductible.   

Consumer had previously spoken with his agent prior to the renewal to discuss if there were any changes to his deductible or water coverage other than premium and was told no.

On the prior term, he had a $500 deductible, but the insurer maintained the $1000 deductible.

Review by GIO:

Once GIO reviewed the Final Position Letter and relevant documents, it was noted on the prior term’s renewal documents that there was reference to “important information” “change to your coverage” where it listed changes to the deductible, co-insurance and/or limits.  The deductible did not change.  However, the current term did not reference the same notification and the deductible was increased. 

GIO was in contact with the insurer for informal conciliation.  Their practice is not to show policy changes on the cover page of renewals.  They state the onus is on the client to review their coverages on renewal.  This consumer relied on his conversation with his agent.

The agent does not remember speaking with the consumer about the deductible, only the rate increase.

Resolution:

The insurer contacted GIO and, given the deductible was not clear to the consumer, their claims department agreed to reduce the deductible to $500 for this claim. 

Consumer was appreciative for GIO’s assistance as he was not able to resolve on his own.