Does this constitute fraud under the Fraud Act 2006?

Valkyrie888

Hello,

I have submitted a claim on my house insurance with H____ P_____. A loss adjustor from G____ S______ was appointed at my behest after I found the performance of the insurer's claims handler below the standard I expected. 

The loss adjustor had stated in an email that the claim would be sent to the underwriters, A___, to determine liability and expected to get an answer within 7-10 days. 

After several weeks had elapsed, I asked the loss adjustor the status of the claim and he said that there was a delay as there were variances from my statement of fact which had been flagged to the Underwriters. He stated that it took  5 and 10 working days for a response from the Underwriters (HP)  to be passed on to the Insurers before being communicated to the loss adjustors (GS). I asked if there was an internal dispute resolution process that I could initiate with the Underwriter, (A); he confirmed that there was but stated "The first stage in this instance if you have a dispute would be to raise it with me and I will happily register it for you."

I contacted the CEO of A (Underwriter), imploring them to deal with my claim fairly and in a timely manner; my request was referred to the complaints department and after I submitted my policy information, I was told that A had no involvement in my claim. 

The loss adjustor responded to an email and provided an update highlighting that the Underwriters were still scrutinising the claim and had not accepted liability. When asked to confirm who was scrutinising the claim, the loss adjustor confirmed that it was A. I immediately contacted A and renewed my queries regarding my claim and their involvement and they refuted all involvement except for handling my initial contact with the CEO. 

I engaged with the Insurer, HP, and relayed some of my concerns regarding the alleged involvement that A was having with my claim; it was confirmed in writing that A had not been involved in the claim and that the Insurer's underwriters had been dealing with the claim. 

Would this code of conduct meet the criteria for a fraud charge under the Fraud Act 2006? 

It is the gain or loss which I am struggling to determine. By false representation/failing to disclose information could it be argued that he undermined my knowledge of the claim with a view to influencing my decision making regarding the claim? 

​​​​​​​Many thanks

dunstonh

Would this code of conduct meet the criteria for a fraud charge under the Fraud Act 2006? 

Probably not, but you can go to the police and see if they consider it worth investigating, and then take it to the CPS to decide.

It is important to not miscategorise incompetence or, misunderstanding or mistakes as fraud. It is also worth noting that if you are being investigated for potentially fraudulent claims, then they would not tip you off and may hide information from you, which may include telling you porkies.

DullGreyGuy

So you have a policy with Home Protect, an MGA/Intermediary who write policies insured by Axa. Guessing the loss adjusters are GHG Solutions but there are a large number of firms out there. 

By "confirm liability" do you mean confirm indemnity, ie they will be paying your claim? Or are you holding a neighbour or something liable for damage to your property?

Not sure what "fraud" you believe may have happened? That you thought Axa were looking at a claim but they weren't? Insurance language isn't always the most helpful, some terms have multiple meanings, some are antiquated so helps if you understand industry history, some are just bad choices of words but have become the standard. 

As an MGA they have delegated authority, or in another way of saying it, Axa has given them their pen. Home Protect are not an insurer but Axa allows them to write business "on their paper" within whatever bounds they've set. This normally also covers claims handling which can be sub delegated to a third party administrator in a claims outsourcing agreement. 

Underwriter isn't a very helpful term, it can be a job title in multiple departments, it can be the entity that sets the price, it can be the company that ultimately is liable to the insured for funding claims. 

If you want help it would be better to say what the claim is, what the issue is and why you disagree than be cryptic about the parties involved or allege fraud etc.

Annemos

Yes I also think there has been a misunderstanding of how some of our Insurance Policies actually work. DullGreyGuy had to sort me out, too, on this issue. I was also totally confused. 

I will use your Company names, but tell you how my Building damage claim was handled. 

AXA was the top Insurer, but they had given Delegated Authority to Home Protect to handle and pay for Claims under a certain monetary amount. (This was set out on my original Policy Document.) 

Then Home Protect had itself given Delegated Authority to GHG to handle the actual claim and for GHG to make the decision if the Claim was valid and then handle the claim. (Again I believe GHG just got on with it, if under a certain monetary amount and GHG considered the claim to be valid.) 

Once there was an issue (in my case, a Complaint about the quality of the Building repair works), the Complaint was made to GSS. Behind the scenes, GSS then had to pass it back to Home Protect for their review and agreement of the resolution. 

But the interesting thing is that neither Home Protect or AXA ever dealt with me directly. That was the whole point of the arrangement! I only ever had dealings with the Loss Adjuster. But as I say, if there were ever any issues, I know Home Protect was being involved and consulted behind the scenes. 

If I had to complain about the Claim Handling, then in my Case the Complaint always went to the Loss Adjuster. (They were acting under Delegated Authority to handle the Claim.)

AXA only gets involved, if a Complaint goes so far without resolution, that a Complaint has to be submitted to the FOS. This is because AXA are held ultimately responsible by the FOS for the other companies with Delegated Authority acting below them. So an FOS Complaint is raised in the name of AXA.
 

So I wonder if GHG had something they wanted to discuss with Home Protect. For example, some reason why the claim is not able to progress. 


If you feel you have got into a knot over this and now want to give GHG time to consider your Claim ...... I would just send the Loss Adjuster an e-mail, saying you have now had an explanation of how Delegated Authority works. Then say you will wait to hear back from GHG itself, how the claim is going to be handled. 

(And if you then don't agree with what they decide, then its a Complaint to GHG.  And then after giving GHG up to 8 weeks to respond, if you still don't agree, then its the Ombudsman process with a Complaint logged against AXA.)


Hope that all makes sense. 

Valkyrie888

DullGreyGuy said:

So you have a policy with Home Protect, an MGA/Intermediary who write policies insured by Axa. Guessing the loss adjusters are GHG Solutions but there are a large number of firms out there. 

By "confirm liability" do you mean confirm indemnity, ie they will be paying your claim? Or are you holding a neighbour or something liable for damage to your property?

Not sure what "fraud" you believe may have happened? That you thought Axa were looking at a claim but they weren't? Insurance language isn't always the most helpful, some terms have multiple meanings, some are antiquated so helps if you understand industry history, some are just bad choices of words but have become the standard. 

As an MGA they have delegated authority, or in another way of saying it, Axa has given them their pen. Home Protect are not an insurer but Axa allows them to write business "on their paper" within whatever bounds they've set. This normally also covers claims handling which can be sub delegated to a third party administrator in a claims outsourcing agreement. 

Underwriter isn't a very helpful term, it can be a job title in multiple departments, it can be the entity that sets the price, it can be the company that ultimately is liable to the insured for funding claims. 

If you want help it would be better to say what the claim is, what the issue is and why you disagree than be cryptic about the parties involved or allege fraud etc.

Thanks for the reply. 

None of those companies you've mentioned are the companies involved. Probably best not to speculate. 

I am using the terms of reference that the the companies involved have used. They have referred to 'liability' as whether they will pay my claim. The insurer and underwriter are the terms of reference the loss adjustor has designated the two companies involved. 

The loss adjustor has repeatedly stated in writing that the claim is being dealt with by the underwriter; it transpires that at no point has the underwriter been involved in the claim. Fraud includes false representation, failing to disclose information or an abuse of power - his conduct meets the definitions under the Fraud Act 2006. 

As I stated in the initial question, can having information withheld or misrepresented constitute a risk of loss? ie I have not been made privy to all of the information which I am entitled to under the FCA principles and as a result could make an ill informed decision.

More of a legal question than an insurance question. 

Valkyrie888

Annemos said:

Yes I also think there has been a misunderstanding of how some of our Insurance Policies actually work. DullGreyGuy had to sort me out, too, on this issue. I was also totally confused. 

I will use your Company names, but tell you how my Building damage claim was handled. 

AXA was the top Insurer, but they had given Delegated Authority to Home Protect to handle and pay for Claims under a certain monetary amount. (This was set out on my original Policy Document.) 

Then Home Protect had itself given Delegated Authority to GHG to handle the actual claim and for GHG to make the decision if the Claim was valid and then handle the claim. (Again I believe GHG just got on with it, if under a certain monetary amount and GHG considered the claim to be valid.) 

Once there was an issue (in my case, a Complaint about the quality of the Building repair works), the Complaint was made to GSS. Behind the scenes, GSS then had to pass it back to Home Protect for their review and agreement of the resolution. 

But the interesting thing is that neither Home Protect or AXA ever dealt with me directly. That was the whole point of the arrangement! I only ever had dealings with the Loss Adjuster. But as I say, if there were ever any issues, I know Home Protect was being involved and consulted behind the scenes. 

If I had to complain about the Claim Handling, then in my Case the Complaint always went to the Loss Adjuster. (They were acting under Delegated Authority to handle the Claim.)

AXA only gets involved, if a Complaint goes so far without resolution, that a Complaint has to be submitted to the FOS. This is because AXA are held ultimately responsible by the FOS for the other companies with Delegated Authority acting below them. So an FOS Complaint is raised in the name of AXA.
 

So I wonder if GHG had something they wanted to discuss with Home Protect. For example, some reason why the claim is not able to progress. 


If you feel you have got into a knot over this and now want to give GHG time to consider your Claim ...... I would just send the Loss Adjuster an e-mail, saying you have now had an explanation of how Delegated Authority works. Then say you will wait to hear back from GHG itself, how the claim is going to be handled. 

(And if you then don't agree with what they decide, then its a Complaint to GHG.  And then after giving GHG up to 8 weeks to respond, if you still don't agree, then its the Ombudsman process with a Complaint logged against AXA.)


Hope that all makes sense. 

Hi, 

I dealt with the insurer initially, and then requested for the appointment of a loss adjustor as the insurers were not meeting my expectations. The loss adjustor became my point of contact and we progressed with the claim. I contacted the CEO of the underwriter to clarify the reason for the delay and they confirmed that they had nothing to do with the claim. I have then spoken to management at the insurer and they confirmed that the underwriter had not had any involvement in the claim. 

Annemos

My Claim Handler was always the Loss Adjuster.

So as soon as I telephoned and opened up the Claim, the "surveyor"...... (I use that term loosely!!) ... came around to view my building. Then a few days later I was told the name of the Claim Handler who was also the Loss Adjuster who was also the Structural Engineer. 


So in your case, the middleman (the MGA), is being referred to as the Underwriter by the Insurance Company.


The problem is perhaps... as far as the Loss Adjuster is concerned, he perhaps also thinks of the Top Insurer as being the Underwriter, so he is not telling a lie? (If he just uses the word Underwriter, as opposed to the actual Company.) 

As DGG says, the word is used interchangeably. Sometimes for the MGA middle company and sometimes for the top Insurer. 

DullGreyGuy

Valkyrie888 said:

DullGreyGuy said:

So you have a policy with Home Protect, an MGA/Intermediary who write policies insured by Axa. Guessing the loss adjusters are GHG Solutions but there are a large number of firms out there. 

By "confirm liability" do you mean confirm indemnity, ie they will be paying your claim? Or are you holding a neighbour or something liable for damage to your property?

Not sure what "fraud" you believe may have happened? That you thought Axa were looking at a claim but they weren't? Insurance language isn't always the most helpful, some terms have multiple meanings, some are antiquated so helps if you understand industry history, some are just bad choices of words but have become the standard. 

As an MGA they have delegated authority, or in another way of saying it, Axa has given them their pen. Home Protect are not an insurer but Axa allows them to write business "on their paper" within whatever bounds they've set. This normally also covers claims handling which can be sub delegated to a third party administrator in a claims outsourcing agreement. 

Underwriter isn't a very helpful term, it can be a job title in multiple departments, it can be the entity that sets the price, it can be the company that ultimately is liable to the insured for funding claims. 

If you want help it would be better to say what the claim is, what the issue is and why you disagree than be cryptic about the parties involved or allege fraud etc.

Thanks for the reply. 

None of those companies you've mentioned are the companies involved. Probably best not to speculate. 

I am using the terms of reference that the the companies involved have used. They have referred to 'liability' as whether they will pay my claim. The insurer and underwriter are the terms of reference the loss adjustor has designated the two companies involved. 

The loss adjustor has repeatedly stated in writing that the claim is being dealt with by the underwriter; it transpires that at no point has the underwriter been involved in the claim. Fraud includes false representation, failing to disclose information or an abuse of power - his conduct meets the definitions under the Fraud Act 2006. 

As I stated in the initial question, can having information withheld or misrepresented constitute a risk of loss? ie I have not been made privy to all of the information which I am entitled to under the FCA principles and as a result could make an ill informed decision.

More of a legal question than an insurance question. 

Unfortunately we do have to speculate when people are being obtuse because relationships between parties are important and many people make mistakes. Seems extraordinarily coincidental that the names match perfectly with the blanks but ok, if you say I am wrong then I am out because if I dont know if its an MGA, a broker or something else then I cannot help. 

Lines blur, I say I've decades working in insurance but I negotiate vast contracts, oversee development and do business cases so do I do insurance, law, IT or accountancy? 

Based on my previous speculation... Home Protect and Axa are both the underwriter because there are multiple definitions and the former has authority to act on behalf of the later and so their actions are that of the PRA authorised company. Somewhat ironically the "Axa" people won't actually be employed by Axa either but thats another matter. 

Valkyrie888

Annemos said:

My Claim Handler was always the Loss Adjuster.

So as soon as I telephoned and opened up the Claim, the "surveyor"...... (I use that term loosely!!) ... came around to view my building. Then a few days later I was told the name of the Claim Handler who was also the Loss Adjuster who was also the Structural Engineer. 


So in your case, the middleman (the MGA), is being referred to as the Underwriter by the Insurance Company.


The problem is perhaps... as far as the Loss Adjuster is concerned, he perhaps also thinks of the Top Insurer as being the Underwriter, so he is not telling a lie? (If he just uses the word Underwriter, as opposed to the actual Company.) 

As DGG says, the word is used interchangeably. Sometimes for the MGA middle company and sometimes for the top Insurer. 

The loss adjustor has stated repeatedly that the claim is being handled by the underwriter - when I clarified who the underwriter is and where the claim is, he has said A____, the company he designates the underwriter. 

I have submitted a Subject Access Request to clarify the schedule of work that has been completed on my claim. 

Regardless, financial information has been mis-represented to me and there has been a failure to disclose information; the impact of this is that I have reacted to the information I have been given/not given and then engaged with another financial company. Furthermore, had I not established that this was factually incorrect and continued believing the narrative from the loss adjustor, I would have made ill-informed decisions, essentially resulting in a risk of loss. 

user1977

Valkyrie888 said:

DullGreyGuy said:

So you have a policy with Home Protect, an MGA/Intermediary who write policies insured by Axa. Guessing the loss adjusters are GHG Solutions but there are a large number of firms out there. 

By "confirm liability" do you mean confirm indemnity, ie they will be paying your claim? Or are you holding a neighbour or something liable for damage to your property?

Not sure what "fraud" you believe may have happened? That you thought Axa were looking at a claim but they weren't? Insurance language isn't always the most helpful, some terms have multiple meanings, some are antiquated so helps if you understand industry history, some are just bad choices of words but have become the standard. 

As an MGA they have delegated authority, or in another way of saying it, Axa has given them their pen. Home Protect are not an insurer but Axa allows them to write business "on their paper" within whatever bounds they've set. This normally also covers claims handling which can be sub delegated to a third party administrator in a claims outsourcing agreement. 

Underwriter isn't a very helpful term, it can be a job title in multiple departments, it can be the entity that sets the price, it can be the company that ultimately is liable to the insured for funding claims. 

If you want help it would be better to say what the claim is, what the issue is and why you disagree than be cryptic about the parties involved or allege fraud etc.

More of a legal question than an insurance question. 

Well, yes, but it's also specifically a criminal law question. Why do you think that might be of any help to you? You can't (realistically) launch a private prosecution, and the police/CPS are hardly likely to be interested. And even if they were, it would take months/years for anything to happen, and the criminal process isn't going to sort out your claim for you anyway.

TSx

This feels like poor communication (endemic with loss adjusters, and I say that having done the job for a short period) rather than anything else. I very much doubt you will be able to meet the criminal burden of proof to demonstrate dishonest intent requires under s3 of the fraud act (failing to disclose information), and as pointed out above, the police will not be interested.

You could make a civil claim but you'd need quantifiable damaged, not just the fact you unnecessarily contacted the ultimate insurer of the policy. The law around damages doesn't consider hypotheticals so it needs to be actual loss.

If you've made a complaint, they will have 8 weeks to respond and then you can take it to the FOS. For the subject access request, they have 30 days (I'm not sure who you've made this to and what the data controller/processor relationship is but it's possible that e.g the Insurer won't actually hold the information you've asked for if it's all with the loss adjuster).

There are a lot of very experienced people on this forum who might be able to give you some further insight (and the best way of getting it sorted) if you can explain what has actually happened, but from the vague details you've given, the best advice is to wait for the outcome of a complaint, assuming you've raised one - although technically if you've expressed any 'material' dissatisfaction they should have already logged it.