Do I have to accept the insurer’s expert report?

No. You can put a competing report or your own evidence to the insurer, and the external scheme will weigh both. Ask for the report first, because responding to a document you have not read is not possible.

Does complaining cost anything?

Internal dispute resolution and the external scheme are both free to the complainant. The external scheme is funded by the financial firms it covers.

How long do I have to complain?

The external scheme applies time limits that run from the insurer’s final decision, so the safe approach is to lodge promptly after the internal process ends, not to establish the exact limit later.

Should I engage a claims-recovery firm?

That is your decision, and the free internal and external processes exist either way. If you do engage one, ask how they are paid, whether the fee is a percentage of the outcome, and whether they hold a licence.

A claim was declined: the steps in order

In short

Ask for the decision and its reasons in writing, with the specific policy term relied on. A verbal decline is not something you can respond to.
Use the insurer’s internal dispute resolution process first. It is free, it is a required step, and decisions are sometimes changed there.
If the internal answer does not resolve it, the external complaints scheme is free and independent. You do not need a lawyer or a paid claims service to use it.

A declined claim is not the end of the process. There is a defined path, every step of it is free, and the steps have to be taken in order.

There is deliberately nothing to buy on this page.

Get the decision and the reason in writing

Ask the insurer for its decision in writing, identifying the policy term it relies on and the information it relied on. A reason expressed as a general statement about cover is not enough to respond to.

Ask for a copy of the policy wording and schedule that applied on the date of the event, and for any assessor or expert report the decision was based on.

The written decision, naming the clause or exclusion applied
The policy wording and schedule in force at the date of the event
Any assessor, engineer or expert report relied on
The file notes about your claim, which you can ask for

Check the stated reason against the policy

Read the clause the insurer named, in the wording that applied at the time, and check whether the facts as you understand them actually fall inside it. Declines commonly turn on the business description, a condition such as a subcontractor insurance warranty, a late notification, or a policy period question.

Write down where you disagree, and what evidence supports your version. A disagreement about facts is treated differently from a disagreement about how a clause is read, and saying which one you are raising makes the complaint clearer.

Use internal dispute resolution

Insurers must have an internal dispute resolution process, and using it is free. Put the complaint in writing, attach your evidence, and ask for a decision within the timeframe the insurer publishes.

Keep it factual and specific: the clause relied on, why you say it does not apply, and what you are asking for. Decisions are changed at this stage often enough to make it worth doing properly.

Take it to the free external scheme

If the internal answer does not resolve it, the complaint can go to the Australian Financial Complaints Authority, the free and independent external dispute resolution scheme for financial firms including insurers. Its decisions bind the insurer if you accept them.

You do not need a lawyer, and you do not need to pay anyone a percentage of the outcome to lodge it. Paid claims-recovery services can be engaged, but the free scheme is available first and using it costs nothing.

Complaining about an insurer, step by step

If the money is the immediate problem

Insurers and financiers have hardship processes, and a declined claim that threatens payroll or a loan is a hardship conversation as well as a dispute. Ask for the hardship team by name instead of raising it inside the claim complaint.

Free financial counselling is available and independent of the insurer. It is a better first call than a paid advocate when cash flow is the pressing issue.

Questions

Do I have to accept the insurer’s expert report?: No. You can put a competing report or your own evidence to the insurer, and the external scheme will weigh both. Ask for the report first, because responding to a document you have not read is not possible.
Does complaining cost anything?: Internal dispute resolution and the external scheme are both free to the complainant. The external scheme is funded by the financial firms it covers.
How long do I have to complain?: The external scheme applies time limits that run from the insurer’s final decision, so the safe approach is to lodge promptly after the internal process ends, not to establish the exact limit later.
Should I engage a claims-recovery firm?: That is your decision, and the free internal and external processes exist either way. If you do engage one, ask how they are paid, whether the fee is a percentage of the outcome, and whether they hold a licence.

Sources

AFCA — The free external dispute resolution scheme for complaints about insurers.
Moneysmart (ASIC) — Regulator guidance on complaining about an insurer and on free financial counselling.