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Welcome to a special Q&A with Susanne Cloete, the Operations Manager at PNOinsurance. In this interview, Susanne delves into a recent monumental win with AFCA, recounting a two-year-long battle for justice on behalf of our client.

We discuss the benefits of having an extremely capable and professional claims team in your corner throughout a complex claim dispute, as we shed light on our commitment to fighting for our clients in the claims process.

1. A PNO client and yourself recently had a substantial win with AFCA. So who or what is AFCA and when do you engage with them?

AFCA is the Australian Financial Complaints Authority. They provide consumers and small businesses with fair, free and independent dispute resolution for financial complaints. They are an external dispute resolution organisation for consumers who are unable to resolve complaints with their insurers.

2. Tell us more about this PNO client and their claim?

Our client is a retail business owner operating from their self-owned commercial property.  They faced significant challenges when extensive rainfall hit Brisbane and its surroundings in February 2022. The inundation led to severe water damage to both the property and its contents, ultimately costing the client hundreds of thousands of dollars. When it came to putting through the claim with the insurer, it resulted in a denial of cover due to a flood exclusion.

The policy excluded coverage for floodwater damage, however the pivotal point rested on distinguishing whether the water that entered the property initially was floodwater or stormwater. We were determined to get the outcome which our client was entitled to. We collaborated with our client’s hydrologist and presented a comprehensive case during the internal dispute proceedings with the insurer. The insurer held firm on the denial and we recommended escalating the matter to AFCA, at no cost to the client.

Navigating through the intricate and lengthy AFCA process, we dedicated a great deal of collective hours advocating for our client. The journey was long and challenging, yet the outcome was incredibly satisfying. Ultimately, we were successful in showing that the damages to our client’s property was caused by stormwater and the insurer was required to pay our client’s claim.  AFCA also awarded our client additional compensation and the costs associated with getting expert reports. Witnessing a fair outcome following such challenging circumstances reinforces our commitment to tirelessly advocate for our clients.

3. Can a policy holder go to AFCA themselves?

Yes, they absolutely can. However, the insurer’s arguments often delve into highly technical aspects such as policy wording interpretations and legal jargon. Success often hinges on an understanding of policy wordings, prior determinations, and relevant case studies – a large part of the support we offer our clients at PNO. Understanding the complexities of AFCA proceedings and technical arguments can be difficult, leading to individuals getting lost in the details. Familiarity with how AFCA operates is crucial for navigating this complex space and having an experienced, competent broker on your side makes all the difference.

4. What is the process of approaching AFCA?

We don’t always recommend every client goes to AFCA when they are unhappy with a claim outcome. If we believe the insurer’s decision aligns with the policy and is fair, we’ll candidly communicate that to our clients, even if it may not be the news they were hoping for. However, when we are of the belief that the decision is incorrect, regardless of the claim type or the claim’s value, AFCA becomes the preferred recourse.

“Our process is meticulous, involving a thorough examination of the claim, past case examples, internal peer discussions, policy wordings reviews”

We always initiate the insurer’s internal dispute resolution procedure beforehand. In cases like the one we’re discussing, we will also leverage external experts such as hydrologists and engineers to build a strong case.

5. Where do you see slip ups when approaching AFCA?

It’s essential to understand what you need to show, prove, or argue to confirm coverage under an insurance policy. Focusing on the wrong aspects may inadvertently jeopardise the opportunity to build a compelling case. In many instances, the outcome can turn on a seemingly minor sentence or exception – elements that might have been initially overlooked. The crux often lies in the specific language used in an expert’s report or the use of a specific word or sentence in a policy exclusion.

What sets us apart is our objective stance whilst supporting our clients. Having not directly experienced the trauma of the event or the financial loss, we bring both a technical lens and a clinical outlook to the table, whilst also providing the empathetic support which clients often need. This unique position allows us to navigate the details and deliver optimal outcomes for our clients. When approaching AFCA, extensive insurance knowledge and a deep understanding of policy wording is key.

6. There’s celebration in our office when a win comes through, why is that?

As a collective, our brokerage is dedicated to advocating fiercely for our clients to ensure they receive the full value of what they’ve paid for. While the majority of claims proceed smoothly and clients obtain their rightful entitlements, the reality is that decisions taken by insurers, are not always right. Mistakes can happen, and perspectives may differ. It is in these instances that we, as brokers, step in to protect the interests of our clients.

So, when we do get these wins, after many hours of hard work, there is rightfully a celebration in our office.

7. The insurer in this case is a key partner of PNO’s. Does this ever have an impact on the decision whether to take a matter to AFCA?

Our relationship with insurers, especially in the claims space, can be combative at times. However, there is always mutual respect, and where we believe that our client deserves a better outcome or where we disagree with the decision taken by an insurer, regardless of who they are, we will not hesitate to fight for what we believe is right.

8. What other claims have you taken to AFCA that have been won?

Our strike record is excellent and we have had a number of wins with AFCA for our clients over the last couple years. We’ve had claim denials overturned across a whole range of products – this includes property and contents claims, cyber losses, thefts, and even a recent travel claim.

At PNO we have a powerhouse of claims knowledge and experience within our claims team, as well as legal expertise We use these complex examples as case studies to help develop our claims and broking personnel across the business.

Our clients and fighting for what’s right is our priority, and we’re truly proud of this win.