EBM - can insurance decide to just not pay some portions?

I've got a claim going through now and EBM has grouped some of the damage together and separated others.

Then they've said the separated damage is uneconomical for them to claim (since it's under the $400 excess), so it won't be covered. They've already applied the maximum 2 excesses but are unwilling to cover the rest.

I've had a look through the PDS and I didn't find anything relating to them covering things at their discretion.

Has anyone gone through anything similar?

 

It partly comes down to how the information presented and structured to them. With all insurance companies there's good / better ways of doing it to maximise what you get out of it.

When they present a settlement $ number to us, I've found they're fairly open minded with our objections / suggestions / questions etc.

But really, it comes down to each individual claim, all of them are going to be different.

 

But isn't it just a case of, insurance policy says they'll cover x, so they're bound to pay x? Are they really allowed to just pay whatever they fancy?

 

In my experience ebm are one of the better ones

But for my last claim I was surprised when they charged two or three excesses for a tenant trashing the place and leaving

I guess you could argue it was one event.

Eg if the house burnt down I doubt they would charge you 20 excesses for every component

 

No, they don't just pay what they fancy.

They will pay the claim depending on what the policy says. Read the fine print, it is all set out.
Marg

 

Yeah that's why I'm confused. Nothing in the PDS even mentions the word uneconomical or less than excess.

They were also unable to point out where in the PDS it said they can pick out which parts to pay out.

I'll push it through complaints and the ombudsman if it comes down to it.

 

I think this bit is common sense.

Say your door is worth $100 and gets kicked in and im your insurer. Give me $400 and I'll give you a new $100 door.

 

I can understand that from the businesses perspective, but coming from the customers perspective, If I don't pursue this, I lose $300. If I do and possibly win, I don't lose $300. It's not a case of paying additional excesses.

They can't charge anymore, so there's no reason not to pursue this and try get back what their policy said they'd pay? It's not going to cost me $400 to get back $300. It's going to cost me $0.

 

If you pursue it you'll pay $400 excess to get a $100 door.
If you don't pursue it, you can pay $100 to get a door otherwise.
They're saving you $300.

 

The insurance process is always more stressful than most people appreciate. It does not sound like they are doing anything untoward or illegal. Inevitably, an insurance event is more costly than most people realize as well. Just keep communicating politely with their representative and give them any evidence they need e.g. quotes. Invariably, these event/s will cost the insurer far more.

 

Your insurer is suggesting that there are multiple events? So one new excess for the $100 door and its not logical to do that as the damage is just $100. Thats normal with tenant damages under a lease unless a single event is capable of being demonstrated eg a fire. They can assume each hole in a wall is a single destructive event. Eg REA inspects on Friday and its all OK and on Sat they have a party and property is trashed. They may treat as one claim. But when a property is damaged over time its seen as multiple events.

They call these people field assessors a loss adjuster for a reason. They never adjust up. Their job is to pay what the policy agrees to pay not what you claim to have lost.

 

Has the whole bond claimed against other items of damage and/or cleaning as they will also contribute some if the amounts claimed against the bond if there is still credit left to be used toward the bond

 

That's correct for the first 2 excesses. But once that excess limit is reached, there is no benefit to not claiming it.

If I have a single bill for 5k, and they've split it into 4 events:
$2250 (Excess 1)
$2400 (Excess 2, maximum number of excesses reached)
$250 (No excess, uneconomical for them to claim, so they won't pay)
$100 (No excess, uneconomical for them to claim, so they won't pay)

Item 3 and 4 isn't saving me any money by not claiming, I'm only losing money. There are no more excesses to pay, but I'm still out a few hundred.

By their logic, what's to stop them from separating everything under $400 as a separate event and not paying it as it's uneconomical (for them).

 

Hi Creamy,
I think I understand what you are thinking. A single invoice does not mean that it is the one job.
Can I give you an example of a job, and see if it is similar to your description.
Let’s say a plumber comes to my house to do some work.
Replace a hot water system, replace a tap in the bathroom, fix a leaking dishwasher.
A single invoice is raised for $1,000 because it is the one plumber and one visit but it is 3 different jobs.
Does this make sense?

 

Sound right. So there are 3 events to the 1 claim.

 

Not quite, just because it is a single invoice does not make it a single claim. It would be 3 separate events/jobs/claim.
3 events = 3 Excesses

 

I think it is going to be up to you to prove that the items you are claiming should actually fall within the ambit of a claim they have agreed to pay.

You haven't said what each claim is in relation to.

 

I just had a similar dicussion with Terri Scheer yesterday. They apply a $250 excess to each event maxxing out at $500 (2 events), BUT each 'event' thereafter is only paid out if the value exceeds $250.

I asked the representative why I wouldn't just suggest that the handyman to quote $250 for every item, which she didn't like.

What a silly procedure.

 

On re-reading this thread, I think I would be after more explanation too. If it was split out as:

And if the policy says you only have to pay two excesses, then on the face of it I would expect that everything after that was fully recoverable.

If the final two things were $401 (with excess of $400) would they have paid the $401 x 2? It seems they are leaving themselves open to strategic billing as suggested above.

 

It is irrelevant that there is a single invoice. May be separate events still (a red wine spill in the lounge room today, another red wine spill in the bedroom tomorrow for example).
You can't stockpile claims over a period then lodge them at the same time and expect to pay only a single excess.