How to dispute a declined claim

A declined claim is a decision, not a verdict. New Zealand’s regulatory structure deliberately builds a second look into the system: an internal complaints process at the insurer, then an independent scheme that reviews the decision at no cost to you. Insurers must belong to one and must tell you which.

The schemes are not toothless. They investigate, they can require the insurer to produce its file, and where they find in your favour they can direct it to pay. Their determinations bind the insurer if you accept them, while leaving you free to go elsewhere if you do not.

The volume tells you they are used. In the year to 30 June 2025 the Insurance & Financial Services Ombudsman scheme received 4,293 consumer approaches and accepted 600 disputes for investigation, with life, health and disability insurance accounting for 29% of them — reported by Insurance Business NZ from IFSO Scheme figures. Most approaches resolve without a formal investigation.

1. 1

   Get the decision in writing

   Ask for the full reasons, the policy clause relied on, and the evidence used. Ask also for the complete policy wording that applied when the policy was issued, and the original application.

2. 2

   Read the wording against the decision

   Work out precisely which words the insurer says are not met. Most successful challenges turn on a definition, a date, or medical evidence that was never obtained — not on fairness in the abstract.

3. 3

   Complain to the insurer in writing

   Address it to the complaints team. Set out what happened, what was decided, why you think it is wrong, and what you want. Attach anything new — a specialist letter, a corrected date. Keep it factual and keep a copy.

4. 4

   Let the internal process run

   The insurer will acknowledge the complaint and give you a timeframe. Use it. An internal review overturns a meaningful share of decisions, particularly where new medical evidence is supplied.

5. 5

   Get the final response

   If the insurer maintains its decision, ask for its final written response — often called a deadlock letter. It should name the dispute resolution scheme the insurer belongs to. If the insurer has not responded within its own stated timeframe, you can generally go to the scheme anyway.

6. 6

   Take it to the scheme

   Complete the scheme’s complaint form and send it with the deadlock letter and your documents. The scheme checks it is in jurisdiction, then investigates. It will ask the insurer for its file.

7. 7

   The determination

   The scheme reaches a view. If you accept it, it binds the insurer. If you do not, you keep your right to take the matter elsewhere, including to court.

Two practical points. Schemes have monetary and time limits, so do not sit on a decline for years. And a complaint about your adviser goes to the adviser’s own scheme, which may be a different one — if the problem originated at the point of sale rather than at the claim, that distinction matters.

These are the details that decide whether the cover does what you expected. Read them before you compare on price.

• Whether you have the complete policy wording as it applied when the policy was issued, not the current version.
• Whether the insurer obtained all the relevant medical evidence, or decided on a partial file.
• Whether a specialist can address the specific contractual test the insurer says is not met.
• Whether the policy has a partial or severity-based benefit that might respond even if the full definition does not.
• Whether the scheme’s monetary and time limits cover your dispute.
• Whether the real issue is the claim decision or the advice given when the policy was sold — they go to different places.

Every New Zealand insurer writes how life insurance claims work to its own wording, and the words are where the money is. Two policies that look identical on price can pay very differently when it matters. Closing that gap is the entire job of an adviser.

• An adviser can read the decline letter against the wording and tell you honestly whether there is a point to argue.
• They can obtain and frame the additional medical evidence that answers the insurer’s actual test.
• They know the insurer’s internal complaints route and often who to send it to.
• They will also tell you when a decline is correct, which saves months of effort — that candour is the point of having one.

There are three ways to buy life cover in New Zealand, and they are not equivalent. You can buy direct from one insurer, which means you see one product range and one underwriting appetite. You can buy through your bank, which usually means a single insurer’s product sold under the bank’s brand, often with narrower definitions. Or you can go through an adviser, who quotes several insurers at once and is required to put your interests first.

The premium you pay is the same either way. Insurers build adviser commission into their pricing whether or not an adviser is involved, so going direct does not get you a discount — it just removes the person whose job is to argue your corner at application and at claim time.

• An adviser can see which insurer is currently taking your health history on standard terms, and which one will load or exclude it.
• An adviser can structure cover across two insurers if that produces a better outcome than putting everything with one.
• An adviser handles the underwriting back-and-forth, and is the person who chases the claim when a family is least able to.
• An adviser has to document why the recommendation suits you, which is a written record you can hold them to.

We are a referral service, not an insurer. We do not quote premiums and we do not sell policies. What we do is put you in front of one licensed New Zealand adviser who can compare the market properly.

1. 1

   You tell us what you are looking at

   The form takes about a minute. Nobody asks for your medical history on a web form — that conversation happens with the adviser, properly, and only once you have decided to proceed.

2. 2

   An adviser calls you

   A licensed New Zealand adviser talks through your situation: who depends on you, what you owe, what you already have in place, and what you are actually worried about.

3. 3

   They compare the market

   The adviser quotes across the major insurers, checks which of them will take your health history on the best terms, and puts the options side by side in writing.

4. 4

   You decide, in your own time

   There is no obligation and no cost to you. If the answer is that you already have enough cover, a good adviser will tell you that.