To explain how home claims work, our editorial team consulted the Insurance Bureau of Canada’s home-claim guide, Ontario’s Insurance Act, FSRA’s insurance complaint process and the General Insurance OmbudService complaint guide.
Adjusters decide what caused the damage, whether the policy covers it, and how much to pay for a claim.
If you’re in a dispute with an insurance company, a home insurance claim adjuster asking for additional information, taking a long time to deal with a claim, or providing a lower-than-expected estimate may not necessarily be acting unfairly.
Read on to find out more about why claims are denied, reduced or delayed and what you can document if you are in this situation. We’ll also outline what happens next in Ontario, including appraisal and proof-of-loss requirements as well as the complaint process in Canada.
How Should You Deal With A Home Insurance Claim Adjuster?
Document everything. Notify insurer of loss as soon as possible, take reasonable measures to protect your home from further damage if it is safe to do so. Maintain a paper trail.
Ask adjuster to separate claim decisions regarding whether or not the cause of damage is a covered cause of loss, what repairs are necessary to return home back to pre-loss condition, how much it costs to repair/replace individual items, and how the application of any policy deductibles and policy limits affect settlement.
Challenge decisions that conflict with the insurance policy, submitted facts, photos, receipts, contractor’s itemized repair estimate, etc.
A normal investigation can include questions about maintenance, prior damage, ownership, receipts, and repair methods. Challenge the investigation if the explanation for the decision contradicts facts/policy, ignores pertinent information, the rationale keeps changing, or agreed-upon deadlines pass with no follow-up timeline.
| Normal claim step | Warning sign worth documenting |
|---|---|
| Requesting a proof of loss or inventory | The insurer will not explain what is missing, repeats the same request after receipt or gives conflicting deadlines. |
| Comparing damage with wear, deterioration or a prior loss | The decision does not identify the observed condition, cause analysis or relevant policy wording. |
| Preparing an insurer estimate | The scope omits visible damage or uses quantities and materials that no one can explain. |
| Offering a preferred contractor | You are told it is mandatory without a policy basis, or responsibility for approvals and warranties is unclear. |
What To Do In The First Hours After A Loss
- If the building is unsafe due to fire, gas, or structural damage, have all occupants leave the building and call the appropriate emergency services.
- Contact your broker or insurer as soon as possible to report the claim, get a claim number, your adjuster’s contact information and emergency-work instructions.
- Before cleaning up, if it is safe to do so, take wide-angle and close-up pictures or videotape showing the cause of the loss, the rooms affected, and your property in general.
- Do not dispose of any damaged property, except items which are unsafe to leave, unless the insurer authorizes disposal. However, if items must be removed, keep samples for examination, take pictures, and keep documentation of the disposal.
- You may take reasonable steps to prevent further damage (for example, board-up, emergency repairs, shut-off of water, etc.). Wait until the insurer has inspected the damage before making permanent repairs unless safety requires it.
- Keep track of any additional living costs your policy may cover, as well as all receipts for emergency repairs or cleanup.
Seven Claim Issues That Can Reduce Or Delay Payment
1. Disagreement About Cause Or Pre-Existing Damage
Many policies exclude gradual damage such as normal wear and tear, maintenance-related damage, or damage caused by certain types of perils. If your adjuster says that your damage was pre-existing, ask him/her to point out what was damaged before your incident.
Ask the adjuster for proof of pre-existing damage, and ask what section of the policy prevents coverage. You can dispute this determination by providing photos of your property before the loss with visible dates, previous contractor reports, maintenance records, reports from emergency contractors, etc. Pre-existing damage (scratches, dents, etc.) does not necessarily negate a claim for new damage.
2. An Incomplete Or Bundled Repair Scope
A short or bundled estimate can mask a valid dispute about scope of repair, measurements, labour, and/or materials. Request specific information about the scope of repair (line items), quantities, labour cost, quality of materials, treatment of sales tax, overhead, etc. Identify anything left out and request an item-by-item estimate from a contractor. Focus on ensuring all damage is repaired consistently with your policy, not on a lump-sum difference between estimates.
3. A Preferred Vendor Or Contractor
Just because a contractor or vendor is preferred doesn’t necessarily mean they offer poor or below-market services. However, according to the Insurance Bureau of Canada (IBC), consumers have the right to use any vendor or contractor.
The insurer will estimate the extent and cost of repairs. Keep in mind that you may be responsible for paying the difference between the contractor’s cost and what the insurer authorizes. Before authorizing repairs, find out:
- Who controls the scope of repairs?
- Who provides any guarantee for repair?
- Who approves changes?
- Is an assignment of rights and/or direction to pay required?
- Who pays for repairs if new or previously undetected damage is found?
4. Proof Of Loss And Other Paperwork
The proof of loss isn’t just aggravating paperwork; it’s a sworn statement that outlines what you’re claiming and what it’s worth. It can set in motion a variety of legal and contractual steps.
Get the rules and the deadline for submitting it in writing; IBC says it’s commonly given a 30-day turnaround, and abide by the regulations in your province and insurance policy.
Answer questions fully and truthfully, ask for help if necessary, get a receipt when you submit it and write “don’t know” rather than guessing if you don’t know the answer.
5. Wear, Deterioration And Policy Exclusions
Sometimes the broken/worn part and the resulting damage are treated differently for coverage purposes. Also, just because something falls into a general exclusionary area does not necessarily determine the claim outcome. Ask for the entire policy exclusion and the basis for applying it to the damage.
An adjuster’s inability to recite exclusions from policy during an inspection may not necessarily mean that the carrier is in error. Ask for the carrier’s coverage position in writing after inspection.
6. Depreciation, Deductibles, Limits And Replacement Holdbacks
Just because your insurer agrees to pay a claim doesn’t necessarily mean they will pay all repair/damage estimates/quotes. Verify the following:
- how the payment was calculated, such as approved scope of work, unit costs, depreciation, deductible, sublimit, and tax
- portions of a claim that may be held back until repairs/replacement are completed
- deadlines and documentation needed to recover replacement cost holdback amounts
- the difference between actual cash value and replacement cost settlements and which one your policy applies to in your situation.
Read More: Compare Actual Cash Value and Replacement Cost in a Home Claim
7. Slow Responses Or Repeated Requests
Keep a list of the dates you’ve spoken to people by phone, documents you’ve provided, and any next steps that were discussed. If they’re not met, send a short message stating what you’ve provided, what is outstanding, who is responsible for the outstanding tasks, and the date you expect everything to be completed.
If delays seem systemic, consider escalating to a supervisor or complaint officer to get a written explanation for ongoing delays and a new completion date.
Read More: See What to Do About a Delayed Home Insurance Claim
Ontario Claim Deadlines And Appraisal
The policyholder must take reasonable steps to minimize further damage, known as mitigation of damages. In addition, the policyholder must give proof of loss as soon as practicable. Once the proof of loss is complete, the claim is then payable within 60 days unless the insurance contract states a shorter time frame. This does NOT mean that the insurer must determine the final value of a claim and pay it within 60 days of the insurer’s original receipt of a claim.
If a disagreement arises after a proof of loss and demand in writing is made by either party regarding the value of property or amount of loss, either party can request an appraisal. Each party names an appraiser, and those appraisers name an umpire. Appraisers will determine the amount of the claim. Note: Appraisers do not determine coverage disputes. They resolve disputes regarding the amount of the claim.
Ontario law bars a party from suing to obtain payment for an insurance claim unless an action is started within one year after the loss or damage. Discussions regarding appraisal or complaint do not necessarily prevent the expiry of these limitation periods. Check with a lawyer early if your claim has been denied, if the first anniversary of your loss or damage is approaching, or if your insurer asks you to sign releases. Note that different rules apply in the other Canadian provinces.
Build A Claim Comparison That Can Be Reviewed
| Disputed item | Insurer position | Your supporting record | Exact question |
|---|---|---|---|
| Roof slope | Repair 4 squares | Contractor measures 6 squares | Which measurement method and waste factor were used? |
| Flooring | Replace damaged room only | Continuous flooring crosses three rooms | What policy wording or repair standard supports the stopping point? |
| Contents item | Actual cash value $300 | Receipt shows $900 purchase price | What age, condition and depreciation rate produced $300? |
| Water source | Long-term seepage | Emergency report records sudden supply-line break | Which evidence and exclusion support the cause decision? |
Give each issue its own row. That gives the adjuster specific issues to answer and makes it easier for a supervisor, ombudsman, or lawyer to review the claim.
Read More: Understand How Home Insurance Deductibles Work
How To Escalate A Home Insurance Complaint In Canada
- Ask the adjuster for their coverage position, estimate, or calculations (as applicable) in writing, and explain what you disagree with. If the issue is not resolved, ask to speak with the adjuster’s supervisor.
- If the issue is still not resolved, submit a written complaint to the insurer. Address the complaint to the insurer’s complaint officer and include the policy and claim number, a brief list of the issues, copies of any supporting information, and the action or response you’re seeking. The insurer will advise you in writing, usually in a final position letter, of its decision once its own complaint process has been completed. You must file this letter with FSRA or GIO.
- After the final position letter, General Insurance OmbudService (GIO) can review home insurance, auto, or business claim disputes if your insurer is a subscriber. Learn more at their website. The ombuds service’s recommendation is not binding.
- Financial Services Regulatory Authority (FSRA) can review a complaint if you’re in Ontario. Learn more at their website. FSRA cannot resolve coverage/contract disputes or make insurers pay claims.
- If your claim was denied, talk to a lawyer to understand your options, the limitation period, the appraisal process and the option to take your insurer to court.