The Insurer Refuses to Pay

1. Why an insurer may refuse
2. The first step is to obtain a written decision
3. Check the contract and the case file
4. Pre-trial claim to the insurance company
5. Applying to the insurance ombudsman
6. When to contact the Agency

Why an insurer may refuse

A refusal must be based on the contract and legislation, not on an employee's arbitrary opinion. Possible reasons: the event does not have the features of an insured event, the risk is excluded from cover, the contract was not in force, the claimant did not prove the circumstances or the amount of harm, or breached a material obligation affecting the right to a payment.

A complete refusal should be distinguished separately from disagreement with the amount of the payment, the application of a deductible, depreciation or a limit, or the calculation of damage. Each dispute requires different evidence.

The first step is to obtain a written decision

Ask the insurance company to give a reasoned written reply stating the facts, the clauses of the contract and the rules on which the decision is based. The oral phrase "there will be no payment" does not allow the lawfulness of the refusal to be properly checked.

Keep the application for the insurance payment, the certificate or confirmation that the documents were accepted, correspondence, notices, the assessment report and proof of sending. If documents were submitted through an app or a personal account, take screenshots showing the status of the request.

Check the contract and the case file

• whether the event was among the covered risks;
• whether the contract was in force on the date of the incident and in the relevant territory;
• whether the deadlines and method of notification were met;
• whether the full list of documents was submitted;
• whether the limit, deductible and other terms were applied correctly;
• whether there is a causal link between the event and the damage;
• whether the damage calculation matches the results of the inspection and the expert examination.

Pre-trial claim to the insurance company

In the claim, state the contract and application numbers, the date of the event, a brief account of the circumstances, the content of the refusal or calculation, your objections and a specific demand. Refer to documents and clauses of the contract, not merely to your disagreement. Attach copies of supporting documents, draw up a list of enclosures and keep proof of receipt.

If a document is missing that can be obtained from a state body, a medical organisation, an appraiser or another party, say so and ask for a reasonable period. Do not alter originals and do not provide information you know to be false.

Applying to the insurance ombudsman

The insurance ombudsman is an independent participant in the pre-trial settlement of disputes between insurance organisations and clients. Since 1 January 2024, applying to the insurance ombudsman has been a mandatory pre-trial step before going to court in an insurance dispute.

Before applying, send the insurer a notice in the prescribed manner. According to official clarifications, you may need to send a copy of the notice three working days before applying to the ombudsman. The specific set of documents depends on the dispute.

What is usually attached

• the application and an identity document;
• the contract or details of the electronic insurance policy;
• the payment application and confirmation that it was accepted;
• the written refusal or the calculation of the insurance payment;
• the notice to the insurance company about the application to the ombudsman;
• police materials, medical documents or the report on the event;
• the assessment report, photos, videos and other evidence;
• a power of attorney, if a representative acts.

Check the current form, contacts and list of documents on the official resource of the insurance ombudsman or in the clarifications of the Agency of the Republic of Kazakhstan for Regulation and Development of the Financial Market.

When to contact the Agency

An application may be sent to the authorised body on questions of the insurer's compliance with legislation and the rights of consumers of financial services. The regulator checks matters within its powers, but does not replace the court in resolving a civil-law dispute and does not determine damage in place of an expert.

When a court is needed

If pre-trial settlement has not produced a result, the dispute may be referred to court in accordance with the established procedure. In the claim it is important to prove the insured event, the amount claimed, performance of the obligations under the contract and the fact that the mandatory pre-trial procedure was completed. Depending on the circumstances, claims may be made for the payment, a penalty or interest, and for documented court costs.

Court proceedings can indeed be complicated: insurance organisations employ specialised lawyers, so where the amount is significant or the legal position is complex, a consultation with a specialist in insurance disputes is useful. However, a promise of a guaranteed win should put you on your guard.

If the payment is understated

Request the full calculation and the report on the basis of which the damage was determined. Compare the list of damage, the cost of work and materials, the coefficients applied, depreciation, the limit and the deductible. If necessary, obtain an independent opinion, ensuring that an inspection is possible and that procedural requirements are met.

If the insurer delays

Check the date on which the full set of documents was submitted. Request written confirmation of which documents were accepted and what is missing. Send your requests through channels that allow the date of receipt to be confirmed. If the deadline has been breached, state this in the claim and in the application to the ombudsman.

Common mistakes by policyholders

• relying only on telephone conversations;
• failing to keep proof that documents were submitted;
• missing the notice or the mandatory pre-trial stage;
• repairing property before inspection;
• demanding an amount without a calculation and supporting documents;
• signing an agreement without understanding its consequences;
• treating an advertising promise as more important than the terms of the contract.

Short procedure

Obtain a written refusal → collect the contract and evidence → send a reasoned objection → notify the insurer and apply to the insurance ombudsman → if necessary, apply to the authorised body and the court.

This material is for information only and is not individual legal advice.