Definition of a complaint
A complaint is the expression of at least one of the following elements that persists after being considered and examined at the operational level capable of making a decision on the matter:
• a reproach against an organisation;
• the identification of a real or potential harm that a consumer has experienced or may experience;
• a request for a remedial action.
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.
The initial expression of dissatisfaction by a consumer, whether in writing or otherwise, will not be considered a complaint where the issue is settled in the ordinary course of business. However, in the event the consumer remains dissatisfied and such dissatisfaction is referred to the person who is responsible for the examination of complaints and designated as such in the organisation’s policy, then it will be considered as a complaint.
However, organisations must refrain from any undue delay in referring a matter to a higher level solely for the purpose of avoiding reporting requirements.
Where a consumer remains dissatisfied after a reasonable attempt has been made to settle the issue, organisations without a multilevel complaint examination structure are then considered to have received a 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.
• A prompt acknowledgement of the complaint, where possible within two business days of receipt.
• In total, the insurer has 56 calendar days from the time the Lloyd’s Canada office forwards the complaint to the broker, to when the final position letter is issued to the insured by the Lloyd’s Complaints team.
In the case of Lloyd’s and where the insured writes to the Lloyd’s Canada office, Lloyd’s Canada will refer the insured’s complaint to the broker who placed the business at Lloyd’s. The broker is instructed to respond directly to the insured, with a copy to Lloyd’s Canada (firstname.lastname@example.org) within 10 business days.
A closing loop e-mail is sent to the insured by Lloyd’s Canada within one to two business days after receiving the stage one response. The file is closed 10 business days after sending the closing loop e-mail.
Should the insured remain dissatisfied with the stage one response, the insured must advise the Lloyd’s Canada office in writing, within 10 business days after receipt of the stage one response. Thereafter the Lloyd’s Canada office will refer the complaint, along with the stage one position, to the Lloyd’s Complaints team, who will review the complaint and reply directly to the insured with a final response letter.
When a complaint is referred to the Lloyd’s Complaints team, it will have the balance of the 56 calendar days to provide a final response letter to the insured. However, if there are unforeseen circumstances where the Lloyd’s Complaints team are not in a position to provide a final response letter within the 56 days, it must advise the insured that the file continues to be in progress. If the insured is not satisfied with Lloyd’s Complaints team’s final response letter, the insured has the right to have the complaint reviewed by the General Insurance OmbudService (GIO) (refer below for details) and for Québec clients, the Autorité des marches financiers (AMF) (refer below for details).
EDR scheme and eligibility
General Insurance OmbudService (GIO)
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.
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.