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ombudsman news

issue 105

September/October 2012

Q&As

What is the difference between a "final response" and a "final decision"? And is an "adjudication" something different? I'm confused!

Jargon is confusing. That's why we really don't like using it. But we do have some standard processes for dealing with cases - and we need to describe the different stages somehow. It might be useful to have a look at the complaints handling rules on our website - where some of the terms you mention are explained. In the meantime, this is what those terms mean.

A "final response" is the answer that a business gives to a consumer when it has investigated a complaint. It usually comes in the form of a letter. Once the business has given its answer - or if it takes more than eight weeks to give an answer - the consumer can bring the complaint to us.

Most complaints that are referred to us are resolved informally by our adjudicators and case assessors. But if necessary, an ombudsman will issue a "final decision" to resolve the dispute formally and bring the process to an end.

An "adjudication" or "assessment" are ways we can set out our view on a case more informally than with an ombudsman's decision.

We might use this where, for example, we think that the business needs to do something to put things right, but we don't fully agree with what the consumer wants. This is sometimes the most practical way to resolve a dispute to the satisfaction of both the consumer and the business.

You can read more about our process in our quick guides for businesses - available in the publications section of our website.

we are an insurance company and one of our customers has made a claim for storm damage to a roof. We sent an appointed loss adjuster out to survey the damage - and their report says that the roof was old and in quite bad condition. Will the ombudsman agree with our decision to turn down the claim because our policy excludes wear and tear?

We would first need to look at what the consumer was told when they took the policy out. We would look at their policy documents. If the exclusion clause is unclear or hard to find, then we may decide that it isn't fair to apply it - even if the roof is in bad repair. If the exclusion is prominent and easy to read, we would move on to consider the circumstances and the evidence available to us.

This might involve analysing the loss adjuster's report, looking at any accompanying photographs and speaking to the consumer and the loss adjuster to hear their accounts of the site visit.

Ultimately, we would need to identify the main cause of the damage. If the roof was in such a bad condition that the damage was likely to happen in the very near future, regardless of the storm, then it might be fair to apply the exclusion.

However, if the extreme weather was the main reason that the roof was damaged, then we would be likely to recommend that the claim is paid.

For more details on our approach to storm damage complaints, have a look at our technical note on storm damage in the publications section of our website.