Insurance Claim Stuck or Delayed: Your Rights and How to Escalate

Insurance Claim Stuck or Delayed: How to Force a Decision

An insurance company that won't make a decision on your claim is engaging in one of the insurance industry's most frustrating tactics. Whether it's endless requests for additional documents, unanswered phone calls, or a claim that sits in "review" for months without resolution, unreasonable delay is not just frustrating — in most countries, it is illegal.

This guide explains your rights, the specific regulatory timelines insurers must comply with by country, and exactly how to escalate when your insurer won't move.

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Why Insurers Delay Claims

Understanding the delay tactic helps you counter it:

• Cash flow benefit: Every day the insurer holds your money, they're earning interest on it
• Attrition: Some claimants give up or settle for less after being exhausted by the process
• Information fishing: Repeated documentation requests may be attempts to find grounds to deny the claim
• Internal processing backlogs: Sometimes delays are genuine (though still not acceptable beyond regulatory limits)
• Complexity assessment: Legitimate large or complex claims sometimes require extended investigation — but even these have regulatory time limits

Regardless of the reason, you have rights — and specific escalation tools available when those rights are violated.

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Regulatory Claim Timelines: What Insurers Must Meet

United States

Under ACA regulations and state insurance laws, health insurers must:

• Acknowledge your claim within 10–15 days
• Request additional information within 15 days
• Decide a non-urgent claim within 30 days of receiving all information
• Decide urgent/expedited claims within 72 hours

State laws vary and are often stricter. California, for example, requires:

• Acknowledge within 15 calendar days
• Accept or deny within 40 calendar days (with extensions only for good cause)

For property insurance, most states require decisions within 30–45 days of receiving proof of loss.

United Kingdom

Under FCA (Financial Conduct Authority) rules:

• Insurers must acknowledge complaints within 5 business days
• They must provide a final response within 8 weeks for most claims
• Claims must be handled "promptly, fairly, and consistently"

If an insurer hasn't resolved your claim within 8 weeks, you can take it immediately to the Financial Ombudsman Service (FOS) — even without a final decision from the insurer.

Australia

Under ASIC's General Insurance Code of Practice:

• Insurers must decide claims within 10 business days in straightforward cases
• Complex claims: decision within 30 business days (with extension possible for exceptional circumstances)
• Insurers must provide a "decision outcome letter" within 5 business days of completing their assessment

AFCA can accept complaints about delayed claims.

Canada

Provincial regulators set timelines, but the General Insurance Code of Conduct requires:

• Response to claims within 10 business days in most provinces
• Final decision within 30–60 days depending on province and claim type

Malaysia

Under BNM guidelines:

• Insurers must acknowledge claims within 3 working days
• Simple claims: decision within 14 working days
• Complex claims: up to 30 working days

Singapore

MAS (Monetary Authority of Singapore) and the Life Insurance Association expect:

• Health claims: decision within 14 working days of complete documentation
• Life claims: within 30 working days

India

IRDAI regulations require:

• Health claim decision within 30 days of receiving all documents
• Where investigation required: within 45 days with written explanation of delay

South Africa

The Long-Term Insurance Ombudsman and Short-Term Insurance Ombudsman guidelines expect:

• Claims decisions within 10 business days for straightforward claims
• Complex cases: no longer than 90 days from date of claim

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Step 1: Create a Paper Trail of the Delay

The first step in fighting a delayed claim is creating an unambiguous documentary record. Starting today:

• Send an email (or registered letter) to the insurer's claims department stating:
  • The date your claim was submitted
  • All documents you have provided and when
  • The regulatory time limit that has been exceeded
  • A formal request for a decision within [specific number] of days
• Request written confirmation of what documents they still need (if they claim to need more)
• Keep a log of every phone call: date, time, agent name, what was said

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Step 2: Escalate Internally in Writing

Send a formal written complaint (not just a call) to:

• The claims manager or supervisor (not the regular claims handler)
• The insurer's formal Complaints Department
• Reference the specific regulatory timeline that has been exceeded

Your letter should include language such as:

"My claim [reference number] was submitted on [date]. As of today [X days] have elapsed. Under [specific regulation — e.g., your insurer's obligations under the FCA's Conduct of Business Sourcebook / ACA regulations / ASIC's Code of Practice], you are required to have provided a decision by [deadline]. I formally request a decision in writing within [14] days. If I do not receive a final decision or a satisfactory interim response within this period, I will escalate this matter to [relevant regulator]."

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Step 3: File a Regulatory Complaint for Delay

Most insurance regulators treat unreasonable delay as seriously as a wrongful denial. You don't have to wait for a final decision before complaining about delay.

Country	Regulator	Complaint Route
USA	State Department of Insurance	State DOI website
UK	Financial Conduct Authority + FOS	fca.org.uk / financialombudsman.org.uk
Australia	AFCA	afca.org.au
Canada	Provincial regulator + GIO	See province
Malaysia	BNM BNMLINK	bnmlink.bnm.gov.my
India	IRDAI	igms.irda.gov.in
Singapore	MAS	mas.gov.sg
South Africa	OSTI / OPFL	osti.co.za / ombudsman.org.za

Insurers respond to regulatory complaints quickly — a formal complaint to the regulator often produces a claims decision within days.

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Step 4: Request an Interim Payment

In many jurisdictions, if liability is not in dispute but the full payment calculation is being assessed, you can request an interim payment — a partial payment of the undisputed portion of the claim while the remainder is calculated.

This is particularly common in:

• Property insurance where the insurer accepts the claim but disputes the repair cost
• Medical insurance where some items are approved and others are under review
• Business interruption claims where some losses are undisputed

Put this request in writing and cite your policy's payment provisions.

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Step 5: Document the Financial Consequences of Delay

If the delay is causing you financial harm — additional accommodation costs because your home is unlivable, ongoing medical expenses, lost income — document this harm in detail. In many jurisdictions, you can claim:

• Interest on the delayed payment amount
• Consequential losses caused by the unreasonable delay
• Bad faith damages (in US states with strong bad faith laws — California, Montana, and others) where the insurer acted unreasonably

Keep all receipts, statements, and records of additional costs caused by the claim delay.

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Step 6: Invoke the Concept of "Waiver" and "Estoppel"

If an insurer delays for an extended period while you continue to provide information and cooperate with their requests, they may be legally prevented (estopped) from later denying the claim on grounds they could have raised earlier. Courts in multiple jurisdictions have found that insurers who conduct extended investigations without raising specific grounds may waive certain defenses.

This is an advanced legal argument — if your claim has been delayed for many months, consult an insurance law attorney who can advise on whether waiver or estoppel arguments apply in your jurisdiction.

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Common Mistakes When Dealing With Delayed Claims

1. Continuing to call without writing. Phone calls don't create the paper trail that triggers regulatory scrutiny. Every escalation must be in writing.

2. Continuing to send documents without a deadline. Responding to endless document requests without setting a firm deadline enables delay. Send the requested documents with a written note that this is the final provision and request a decision by a specific date.

3. Not knowing the regulatory timeline. If you don't know the deadline the insurer must meet, you can't invoke it. Research the specific rule for your country and claim type.

4. Waiting too long before complaining to the regulator. Regulators can accept delay complaints while the claim is still open. You don't need a final decision.

5. Accepting "we need more time" without a specific date. Get any extension of the review period in writing with a specific new deadline. Vague promises to "continue investigating" are not acceptable.

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Getting Help With Your Delay Escalation Letter

A formal letter threatening regulatory escalation — with specific regulatory deadlines cited — often produces immediate action from insurers. ClaimBack can help you generate a professionally worded delay escalation letter tailored to your country and insurance type, including the specific regulations your insurer is breaching. Visit claimback.app to get started.

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Summary: Delayed Claim The Full Fight

1. Create a paper trail — write today, document everything
2. Escalate internally with a specific deadline and regulatory reference
3. File a regulatory complaint — you don't need a final decision to do this
4. Request an interim payment on undisputed portions of the claim
5. Document financial consequences of the delay for potential consequential loss claims
6. Seek legal advice if the delay has caused substantial financial harm