Canada

Definition of a complaint

Complaints are generally expressed in writing through correspondence, e-mail, fax or other form that allows a complaint to be kept on file. Where a consumer makes a complaint by phone or in person and the complaint is handled and examined by the person responsible for the examination of complaints and designated as such in the organisation’s policy, the complaint must be documented so that it can be kept on file.

A Reportable Complaint means any reproach or dissatisfaction expressed either in writing or verbally, in respect of a service or product offered by Lloyd’s Underwriters related to a policy or claim issued by Lloyd’s Underwriters Canada and could not be resolved immediately within the normal course of business to the satisfaction of the party voicing the concern.

Reportable complaints will follow the tier one/tier two processes.

The Market must apply judgment when determining if a complaint is reportable. In a case when it is unclear or there is doubt, the complaint must be treated as a reportable complaint.

Definition of a complainant

A consumer means all current and prospective customers of insurance products.

Application of Lloyd’s procedure and local complaint regulations

Federal - The Office of the Superintendent of Financial Institutions (OSFI) regulates and supervises all banks and federally incorporated or registered trust and loan companies in Canada, as well as insurance companies.

All federally regulated financial institutions are required by the Insurance Companies Act to have dedicated procedures as well as personnel in place to deal with consumer complaints.

The Insurance Companies Act S.C. 1991, c. 47 is the primary legislation governing all federally incorporated or registered insurance companies in Canada.

Reporting of complaints is not specifically addressed in all jurisdictions other than a general requirement that insurers have a duty to furnish the superintendent on his request for full information.

Tier one and tier two complaints

A tier one complaint is a complaint that can be addressed within 20 days by the Lloyd’s Market (for example, Coverholders, Third Party Claims Administrators, and Managing Agents).

A tier two complaint is a complaint that has been escalated to the Complaints Management Office. The Complaints Management Office means the Lloyd’s Canada, Chief Regulatory & Compliance Officer (CRCO) who is the designated Complaints Manager/Ombudsman. The CRCO delegates the handling and response of a tier two complaint to the Lloyd’s Complaints Department (LCD).

Process

Receiving Complaints

Complaints related to a Canadian policy or claim should be sent to the Lloyd’s Canada Service Desk at info@lloyds.ca immediately.

Complaints can be initiated by a complainant either by mail, phone, or email.

If the complaint is received verbally, the complainant will be encouraged to provide a written complaint. However, if they are unable to do so, the complaint will be summarized in writing by the service desk team. A copy of the complaint summary will be sent back to the complainant either by email or mail.

All complaints are acknowledged within two business days by the Lloyd’s Canada Service Desk of the complaint being received by them.

In the event that a complaint is received through a regulatory body, this will initiate the Complaint process. As well, there may be an obligation to respond to the regulatory body which will be done by the Lloyd’s Canada Service Desk.

Coverholders must ensure they notify their Managing Agents of the complaint directly.

Assessing and Assigning Complaints

Complaints will be assigned for a tier one review assuming that the concerns can be addressed within 20 Calendar Days by the Market Participant.

Complaints of a serious nature (allegations of fraud, material misrepresentation, or misconduct) may be escalated directly to a tier two review. The CRCO may also, at their discretion, select complaints to review personally, (instead of the LCD team) which are deemed as exceptions.

Where there is an obligation to respond to the regulatory body, the response will be managed by the CRCO.

Analysis and Response Tier One

Tier one complaints are reviewed and responded to by the applicable Market participant (Coverholder, TPA, Managing Agent), within 20 days.

Tier One response letters, regardless of the resolution, must contain the internal and external escalation wording. Please see the example below.:

Should you remain dissatisfied with this response, you may request that we refer your complaint to “Lloyd's Complaints Department”, who will review the complaint and reply to you directly.

Also note that if your concerns are not addressed to your satisfaction, you have the right to continue to pursue the complaint with:

1. General Insurance OmbudService (GIO): assists in the resolution of conflicts between insurance customers and their insurance companies. The GIO can be reached at: Toll free number: 1-877-225-0446 www.giocanada.org

2. And/or, for Québec complainants: Autorité des marchés financiers (AMF): Toll Free: 1-877-525-0337 Québec: (418) 525-0337 Montréal: (514) 395-0311 www.lautorite.qc.ca

For further information, please consult the Lloyd's Underwriters' Policyholders' Complaint Protocol.

Escalation to Tier Two

After a tier one review, should a complainant remain unsatisfied, the complainant may request a review of their concerns by the Complaint’s Manager.

As well, some claimants may escalate directly to tier two review if the circumstances require.

When requested, the Service Desk will escalate the complaint to the Lloyd’s Complaints Department (“LCD”). The CRCO may review tier two complaints personally when a regulatory authority or Industry Ombudsman is involved, or at the discretion of the CRCO as they see needed.

Tier two responses must be issued within 56 days of original receipt. Response letters must contain the external escalation wording.

The Financial Consumer Agency of Canada (FCAC) investigates complaints about financial institutions that relate to possible breaches of market conduct obligations. This can be a breach of a law, regulation, code of conduct or public commitment. Regulated Entities (REs) must submit any reportable compliance issue within 56 days of the compliance issue being reported to their compliance division.

According to sections 486, 486.1 and 487 of the Insurance Companies Act and related regulations, insurance companies must:

• file their complaint-handling guides with FCAC’s Commissioner,

• include information about how consumers can contact FCAC,

• include access to an independent organization responsible for dealing with customer complaints that have not been resolved to the customer’s satisfaction through the complaint-handling guides,

• post the guides on their websites offering products or services in Canada,

• provide the guides in writing to anyone who requests them.

Insurance companies must also refile a copy of their complaint-handling guides when a significant change to their guides has been made.

EDR scheme and eligibility

General Insurance OmbudService (GIO)

www.giocanada.org

The General Insurance Ombudsman Service is an independent organisation, created in 2002, with the sole purpose of helping Canadian consumers resolve disputes or concerns with their home, auto or business insurers.

The GIO deals with complaints relating to home, automobile, commercial and accident and sickness for any federally licensed company in Canada that is a member of the GIO.

For Québec clients, as well as contacting GIO, they may also refer their complaint to:

Autorité des marches financiers (AMF):

The AMF is the body mandated by the government of Québec to regulate the province’s financial markets and provide assistance to consumers of financial products and services.

https://www.lautorite.qc.ca/en/

If policyholders have a complaint specifically about Lloyd`s Underwriters’ complaints handling procedures, policyholders may contact the Financial Consumer Agency of Canada (FCAC). The FCAC ensures federally regulated financial entities comply with consumer protection measures, promotes financial education and raises consumers’ awareness of their rights and responsibilities. The FCAC does not get involved in individual disputes.

Local Regulatory Reporting Requirements

The provincial regulators regulate market conduct and the licensing and supervision of insurance intermediaries, such as agents, brokers and adjusters.

The Canadian Council of Insurance Regulators (CCIR) represent the provincial/territorial insurance regulatory authorities. It is an inter-jurisdictional association of insurance regulators. The mandate of the CCIR is to facilitate and promote an efficient and effective insurance regulatory system in Canada to serve the public interest. They work together to develop solutions to common regulatory issues.

Through the CCIR Annual Statement, insurers are required to file information related to their governance, practices and policies with respect to the fair treatment of consumers.

Insurers are required to complete/file Annual Statement by May 1.

The Insurance Companies Act of Canada requires licensed insurers to have a complaints procedure and join an independent organization to mediate complaints that have not been resolved to the satisfaction of the consumer through the insurer’s own internal procedures. To comply with these requirements, Lloyd’s is a member of the General Insurance OmbudService (GIO). In this regard, every Lloyd’s underwriting member carrying on Canadian business and every managing agent acting on their behalf is required to conform to and abide by GIO standards. The GIO is the dispute resolution body for all Canadian jurisdictions, with the exception of Québec.

The Financial Consumer Agency of Canada (FCAC) is an independent body working to protect and inform consumers of financial products and services. It supervises federally regulated financial institutions to ensure compliance with federal consumer protection laws that apply to insurance companies, amongst other entities.

According to the Financial Consumer Agency of Canada (FCAC), the insurer has 90 days from the time the Lloyd’s Canada office forwards the complaint to the intermediary, to when the final position letter is issued to the insured by the Lloyd’s Complaints team.

Relative to FCAC, further information is available on Crystal, refer to Processing and Servicing of Risks and Complaints.

The OmbudService for Life & Health Insurance (OLHI) is an independent complaint resolution and information service for consumers of Canadian life and health insurance. It includes resolving insurance complaints about disability, employee benefits, travel, and investment products such as annuities and segregated funds. OLHI’s operations are overseen by the Canadian Council of Insurance Regulators (CCIR), as well as their independent Board of Directors.

Lloyd’s Complaint Notice

The Lloyd’s Underwriters’ Policyholders’ Complaint Protocol for Canada is LSW 1542F and is published on the Lloyd’s Wordings repository in English and French. It is also referenced in the Pre-contractual notification and Insurance documents sections of Crystal.