15JComplaints about decisions of insurers

#### 15J Complaints about decisions of insurers (1) Subject to subsections (3) to (6) and to section 15K, a person may, at any time, complain to the Tribunal that a decision of an insurer in relation to a contract of insurance where the premiums are paid from an RSA, is or was unfair or unreasonable. > Note: Although a complaint is about a decision of an insurer, the Tribunal may join the RSA provider and any other person, as parties to the complaint (see subsection 18(3B)). The Tribunal may then review any decision of the person joined that may be relevant to the complaint. (2) If a person is given a notice by an insurer in respect of a contract of insurance setting out: (a) the insurer’s decision in relation to the person’s objection to the proposed payment of a death benefit in relation to the contract of insurance; and (b) the prescribed period within which the person must complain to the Tribunal about the decision; the person may only complain to the Tribunal within that period. (3) The Tribunal cannot deal with a complaint under this section that must be made within the prescribed period referred to in subsection (2) if the complaint is not made within that period. (4) The Tribunal cannot deal with a complaint under this section to the extent that it relates to the management as a whole of: (a) an insurer; or (b) an insurer’s business; or (c) an insurer’s investments. (5) The Tribunal cannot deal with a complaint under this section about a decision of an insurer relating to the payment of a disability benefit because of total and permanent disability unless the complaint is made within a period of one year after the making of the decision to which the complaint relates. (6) The Tribunal cannot deal with a complaint under this section about a decision of an insurer relating to the payment of a disability benefit because of total and permanent disability if: (a) before the making of the decision, the person permanently ceased particular employment because of the physical or mental condition that gave rise to the claim for disability benefit; and (b) the claim was not lodged, or is not lodged, with the insurer, within one year after the person permanently ceased that employment because of the physical or mental condition. (7) Without limiting the meaning of a decision of an insurer relating to the payment of a disability benefit in any other provision of this Act, that expression means, for the purposes of subsections (5) and (6), the original decision of the insurer in relation to the matter. (8) For the purposes of subsection (7), if, as a result of a complaint about the original decision of the insurer under arrangements made for dealing with complaints, the original decision was confirmed or varied, or another decision was substituted for the original decision: (a) the decision as so confirmed or varied, or the substituted decision, is taken to be the original decision; and (b) the decision as so confirmed or varied, or the substituted decision, is taken to have been made at the time when the original decision was made. (9) A complaint under this section is to be made by sending or delivering a written complaint to the office of the Tribunal. (10) When a complaint is made under this section about a decision of an insurer in relation to a contract of insurance entered into in connection with an RSA, the Tribunal must, in determining whether that decision is or was unfair or unreasonable, have regard, in particular: (a) to the seriousness of any failure to discharge an obligation under the terms of the contract of insurance; and (b) to any action taken by the insurer that is contrary to the best interests of the RSA holder or any other person having an interest under the contract of insurance.