What happens when the ceiling falls in?

Household insurance may be less comprehensive than you expect. By Paul Gosling

In June this year the ceiling of Neil Davidson's Glasgow flat fell in. The property was well maintained, there had been no floods in the building that he knew of, and there was no obvious cause. Mr Davidson assumed that his insurance policy would meet the repair cost, especially when a survey commissioned by him concluded that the damage was caused by a leak from the roof.

Sadly for Mr Davidson, he found the protection of insurance to be less comprehensive than he assumed. A loss adjuster brought in by the insurer, Independent Insurance, concluded that there was no proof that the collapse had actually been caused by a storm or damage to the roof, and the claim was rejected. The loss adjuster had examined weather records for June and there had been no storms registered that, in his view, would have caused the collapse.

Independent Insurance, when rejecting the claim, wrote: "The burden of proof of loss by a peril as described in the policy rests firmly with the policyholder and unless they discharge that proof then there are no grounds upon which to meet a claim under the policy." In plain English the policyholder has to prove the cause and effect for a claim to be valid.

Mr Davidson's father, Dr Campbell Davidson, has now referred the case to the insurance ombudsman, saying that where there is doubt the insurer should accept liability. "While one can sympathise with insurance companies," Dr Davidson says, "one also has to acknowledge that claiming appears to be a particularly difficult procedure." He says it is unfair that the onus of proof should be on the claimant, particularly when they are refused access to the loss adjuster's report.

Dr Davidson says that he will in future consider more carefully what risks are included in a policy, and what perils are excluded. He also believes there should be a legal requirement on insurers to release the contents of any survey commissioned by them.

Malcolm Tarling, spokesman for the Association of British Insurers, says this is often what happens. "There is no legal obligation to show the loss adjuster's report as it is paid for by the insurer. A surveyor's report is slightly different. If the insured has his own report and there is any conflict it is not unusual to show the insured any conflicting information."

Mr Tarling says that in practice it is usually up to the insurer to disprove that a claim was valid. Most claims are clear, he says, but one exception to this is with water penetration, for which it can be difficult to find the cause.

"You can end up with one expert saying one thing, and another the other, which goes to arbitration by the insurance ombudsman. That is a recognised arbitration system, provided the insurer is a member of the scheme, which most are."

Dr Davidson has now referred the dispute to the insurance ombudsman, and a spokeswoman for Independent Insurance said: "That is the complaints procedure which should have been followed in the first place."

Michael Lovegrove, a spokesman for the insurance ombudsman, said: "The onus of proof lies with the policyholder. Water damage is a hoary old chestnut. We get lots of claims over this. The peril insured is storm. There is no precise legal definition of what constitutes a storm, but there is legal guidance, and it is more than just heavy rain.

"You often get a roof worn out, especially flat felt roofs, and it rains and gets damp and the insurer says there is no evidence of storm damage. When we look at this we do want to look at meteorological records; there has to be a specific storm on a specific day. Sometimes we do find in favour of the policyholder."

An insurer is also entirely justified in withholding the loss adjuster's report and survey, says Mr Lovegrove, since it is commissioned and paid for by the insurer.

"We would look at the policyholder's own report and survey. If we have doubts we may commission a report ourselves. This applies to any case..." he said.