Insurance Claim Denied or Delayed? How to Get Your Insurer to Pay (Australia 2026)
Last updated · Reviewed by the Claim Done team · Not legal advice
Yes, you can challenge an insurer that denies, delays or underpays your claim, and often get it paid. The Insurance Contracts Act requires insurers to act with the utmost good faith (s 13), and the General Insurance Code of Practice sets a 4-month deadline for most claim decisions and 30 days for complaints. The free Australian Financial Complaints Authority (AFCA) can order the insurer to pay, binding it if you accept. Fastest route: complain to the insurer, send a formal complaint, go to AFCA, then a final demand or court only if needed.
Can you get your money back from an insurer?
Usually the question is not a refund but getting the insurer to pay the claim properly: to accept a claim it denied, to decide a claim it is sitting on, or to pay the full value instead of a lowball figure. The rules come from three places:
- The Insurance Contracts Act 1984. Every insurance contract includes a duty on both sides to act “with the utmost good faith” (s 13). An insurer that breaches it contravenes the Act and faces a civil penalty. An insurer cannot rely on a policy term where doing so would breach that duty (s 14). Section 54 stops many claim refusals based on something you did or did not do after the policy started. Section 57 makes the insurer pay interest on a claim it unreasonably held back.
- The General Insurance Code of Practice. The 2020 Code, last updated in October 2023, sets the timeframes for claims and complaints for insurers that subscribe to it. A redrafted Code went through consultation in 2026 but is not in force.
- The ASIC Act. Insurance is a financial product, and handling and settling claims is a financial service. Misleading or deceptive conduct in relation to financial services is banned (s 12DA).
The general Australian Consumer Law guarantees for services do not apply to a contract of insurance (ACL s 63). That is why insurance disputes run on the Insurance Contracts Act, the Code and AFCA rather than on consumer guarantees.
What an insurer cannot do:
- Sit on your claim indefinitely. Under the Code it must decide within 4 months of receiving your claim (12 months only in listed exceptions such as an extraordinary catastrophe or suspected fraud), or tell you in writing about its complaints process.
- Deny a claim without reasons. It must tell you in writing which parts it does not accept and why, and give you the information and expert reports it relied on if you ask.
- Refuse a claim over an act that did not cause the loss. If something you did after the policy started did not cause or contribute to the loss, s 54 limits the insurer to reducing the claim by any real prejudice to it.
- Rely on a term in bad faith. Section 14 stops an insurer relying on a policy provision where that would be a failure to act with the utmost good faith.
- Leave a complaint unanswered. It must decide a complaint within 30 calendar days, or tell you in writing before then why it is late and that you can go to AFCA.
The most common problems with insurers
1. Claim denied
The insurer says the event is not covered, an exclusion applies, or you breached a condition. Ask for the written reasons and the information it relied on. Check the policy wording yourself. Claim acceptance of the claim, or the parts that are covered. AFCA lists denial of a claim as a core insurance complaint.
2. Claim delayed for months
Endless requests for documents, no assessor, no decision. The Code requires the insurer to tell you within 10 business days what information it needs, update you at least every 20 business days and decide within 4 months. Claim a decision, and interest under s 57 if payment was unreasonably withheld.
3. Lowball offer or underpaid claim
The insurer accepts the claim but offers far less than the cost of repair or replacement. Get your own written quotes or valuation. AFCA considers disputes about “the value of an assessed loss”. Claim the difference between the offer and your properly evidenced loss, up to the policy limits.
4. Cash settlement that will not cover the repairs
For home building claims, insurers sometimes offer cash instead of doing the repairs. Under the Code they must explain how cash settlements work and how the figure was reached. Compare it to independent builder quotes before you accept, and ask for the scope of works behind it.
5. Claim refused because of something you did after taking out the policy
For example the house was left vacant longer than the policy allowed, or a car was driven by someone not listed. Section 54 says the insurer cannot refuse just because of that act if you can show it did not cause or contribute to the loss, although it can reduce the payment to reflect real prejudice to it. Claim payment of the claim, less any proven prejudice.
6. Investigations and accusations of fraud
The insurer appoints an investigator and the claim stalls. It must tell you within 5 business days that it has appointed one and what their role is. An investigation does not stop the duty of utmost good faith. Keep records of every interview and request.
7. Travel insurance refused for a pre-existing condition
AFCA lists this as a complaint type. Check exactly what the policy says about pre-existing conditions and what you disclosed. Claim the covered costs if the condition was not excluded or was assessed and accepted.
8. Car accident: liability or excess disputes
Your insurer says you were at fault, or charges an excess you should not pay. AFCA considers disputes about liability for a car accident and about the excess. Claim the excess refunded and the claim treated as not-at-fault where the evidence supports it.
9. Landlord insurance and tenant damage
Claims refused because the damage was not caused maliciously by the tenant are another AFCA complaint type. The answer turns on the policy wording, so get the definition of malicious damage in writing.
10. Premium charged wrongly or not refunded on cancellation
Premiums incorrectly applied or calculated are within AFCA’s reach. Under the Code, if you cancel a policy and are entitled to a refund, the insurer returns it within 15 business days (different arrangements apply if you used a broker).
The insurance rules: utmost good faith, the Code’s deadlines and AFCA
The General Insurance Code of Practice: key deadlines
| What the insurer must do | Deadline | Code paragraph |
|---|---|---|
| Tell you what information it needs and the likely timeframe | Within 10 business days of receiving the claim | 68 |
| Update you on progress | At least every 20 business days | 70 |
| Answer routine enquiries about the claim | Within 10 business days | 71 |
| Tell you it appointed an assessor, adjuster or investigator | Within 5 business days | 72-73 |
| Decide once it has all information | Within 10 business days | 76 |
| Decide the claim overall | Within 4 months of receiving it (12 months in listed exceptions) | 77-78 |
| Give copies of reports it relied on, when you ask | Within 10 business days | 82 |
| Update you on a complaint | At least every 10 business days | 146 |
| Decide your complaint | Within 30 calendar days | 147 |
If you show an urgent financial need while a claim is being assessed, the Code says the insurer will pay an advance within 5 business days. If you apply for financial hardship support, it must tell you its decision in writing within 21 calendar days (longer only if it asks you for more information).
The duty of utmost good faith
Section 13 of the Insurance Contracts Act implies into every insurance contract a requirement that each party act towards the other “with the utmost good faith”. It covers how the insurer handles and settles claims. Since an insurer breaching it contravenes the Act with a civil penalty of 5,000 penalty units, and ASIC can act against an insurer’s licence over bad-faith claims handling (s 14A), it is worth naming in your complaint when an insurer is unreasonable, slow or unfair.
AFCA for insurance complaints
- Free: AFCA describes its service as “fair, free and independent”.
- Insurer first: AFCA may refer your complaint back if it has not been through the insurer’s complaints process (Code para 155). You can go to AFCA at any time, and once the insurer has not resolved your complaint within 30 calendar days (para 154).
- What it covers: home and contents, car, travel, pet, landlord, strata, income protection, life and small business insurance, among others. Not private health insurance (the Private Health Insurance Ombudsman handles that), workers compensation or compulsory third party insurance.
- Binding on the insurer if you accept: AFCA can require the insurer to “meet a claim under an insurance policy”. If you accept a determination, the insurer must comply; if you reject it, you can go to court.
- Limits: up to $631,500 for most direct financial loss, $6,300 per claim for non-financial loss, with special caps such as $316,000 for general insurance broking and $19,000 for uninsured third-party motor vehicle claims.
- Time limits: six years from when you became aware of the loss, or two years from the insurer’s final answer, whichever comes first.
What you can claim from an insurer
- The claim paid, in full or the covered part, up to the policy limits and less any excess.
- The difference between a lowball offer and your properly evidenced loss.
- Interest under s 57 from the day it became unreasonable for the insurer to withhold payment.
- Compensation for financial loss caused by the insurer’s handling, and limited amounts for non-financial loss through AFCA.
- Premium refunds where the premium was wrongly calculated or you are entitled to a refund on cancellation.
To work out the amount, start with the policy schedule (sum insured, limits and excess), then add your evidence of the loss: repair quotes, replacement prices, invoices. Subtract what the insurer has paid and the excess. Note the date you lodged the claim and the date the insurer had everything it needed, because interest and the Code deadlines run from those dates.
Worked example (round numbers, for illustration only): a storm damages your roof. Two builders quote $18,000 to repair it. The insurer offers a $9,000 cash settlement based on its own scope. Your excess is $1,000. Your claim: $18,000 – $1,000 excess – $9,000 already offered = $8,000 more, plus interest from when the insurer should have paid, plus the cost of temporary tarping you paid for while waiting.
Evidence to gather
- Your policy schedule and the full policy wording (product disclosure statement) for the period of the loss.
- Your claim form, the date you lodged it and the claim number.
- Photos and videos of the damage, taken as soon as possible, and anything that shows the cause.
- Independent quotes or valuations, with a scope of works for building damage.
- Every letter and email from the insurer, including requests for information and your replies with dates.
- The insurer’s written reasons for denial or underpayment, and the assessor’s, builder’s or expert reports it relied on (ask for them in writing).
- Receipts for emergency repairs, temporary accommodation or other costs while you waited.
- Police, fire service or weather reports where the cause is in dispute.
- A timeline: lodgement, each request, each response, each missed deadline.
How to get your money back: 5 steps
Step 1. Complain to the insurer
Ask for the decision in writing with reasons, and copies of the reports it relied on. Then make a complaint, saying what you disagree with, the amount you say is payable and the deadline the Code sets. If the claim has gone past 4 months without a decision, say so. Ask for the complaint reference number and the name of the person handling it.
Step 2. No answer or a refusal: send a formal insurance complaint
If the insurer stands by the denial, keeps you waiting or will not move on the amount, put a formal complaint in writing. Ours sets out the facts, the policy wording, the Insurance Contracts Act duty of utmost good faith, s 54 where it applies, the Code deadlines the insurer has missed and the amount you want. It is the formal complaint the insurer must decide within 30 calendar days, and it is ready to go to AFCA if the insurer does not fix it.
Prepare your insurance complaint – $97
More about it: insurance complaint. For a dispute with a business that is not an insurer, our general letter of demand may fit better.
Step 3. Take it to AFCA
If the insurer’s final answer does not fix it, or 30 calendar days pass without one, lodge with AFCA online or call 1800 931 678. It is free. Attach your formal complaint, the insurer’s response, the policy and your quotes. AFCA tries negotiation or conciliation first, may give a preliminary assessment, and can make a determination requiring the insurer to pay the claim. If you accept it, the insurer must comply.
Step 4. Still unpaid: send the final demand
Use this if the insurer agreed to pay and has not, or if AFCA cannot take the complaint (for example private health insurance, a non-member, or out of time) and you want a last formal demand before court. Quote your complaint, the insurer’s response and any AFCA reference.
Step 5. Court, only if AFCA cannot help or you reject its decision
For insurance disputes AFCA is the main route: it is free, it can order the insurer to meet the claim, and its decision binds the insurer if you accept it. A court claim is the fallback if you reject a determination or AFCA cannot consider the complaint. Whether a state tribunal can hear a claim against an insurer depends on the state and the claim, and we have not confirmed it state by state, so check with the registry first. Large or complex claims should get legal advice.
Prepare your tribunal application – $97
In WA, SA and Tasmania the forum is the Magistrates Court, and the same service prepares your court claim. For photos, quotes and reports in hearing order, use the Hearing Bundle ($97).
Where your claim goes in each state
First stop everywhere: AFCA, afca.org.au, 1800 931 678. AFCA covers insurers in every state, so your state does not matter. Private health insurance complaints go to the Private Health Insurance Ombudsman instead.
If you end up in a tribunal or court, it is the one in the state or territory where the business is, and only if that forum can hear your type of claim. For the NSW and Victorian tribunals (NCAT and VCAT), if the business is an individual or sole trader living in another state, the tribunal cannot decide the claim and it must go to a court (Burns v Corbett [2018] HCA 15). QCAT in Queensland is a court of a State (Owen v Menzies [2012] QCA 170) and is not affected. Insurers are companies, so that rule rarely matters here.
| State | Tribunal or court for consumer claims | Money limit | Link |
|---|---|---|---|
| NSW | NSW Civil and Administrative Tribunal (NCAT), consumer claim | $100,000 | ncat.nsw.gov.au |
| VIC | Victorian Civil and Administrative Tribunal (VCAT), goods and services | No cap | vcat.vic.gov.au |
| QLD | Queensland Civil and Administrative Tribunal (QCAT), minor civil dispute | $25,000 | qcat.qld.gov.au |
| ACT | ACT Civil and Administrative Tribunal (ACAT), civil dispute | $25,000 | acat.act.gov.au |
| NT | NT Civil and Administrative Tribunal (NTCAT), small claim | $25,000 | ntcat.nt.gov.au |
| WA | Magistrates Court of WA | $75,000 (minor case up to $10,000) | magistratescourt.wa.gov.au |
| SA | Magistrates Court of SA, civil claim | $100,000 (minor claim up to $12,000) | courts.sa.gov.au |
| TAS | Magistrates Court of Tasmania (Civil Division) | $50,000 (minor civil claim up to $15,000) | magistratescourt.tas.gov.au |
Filing fees change each year and depend on how much you claim and whether you hold a concession card, so check the current fee on the tribunal or court’s own fees page (linked in the table) before you file.
AFCA cannot consider a complaint a court has already decided. Most insurance disputes are best taken to AFCA first.
After you win: getting paid
If you accept an AFCA determination, the insurer must provide the remedy within the time AFCA sets, generally 30 days, and AFCA reports a firm that does not comply to ASIC. If you went to a court or tribunal instead and the business does not pay by the date in the order, the order can be enforced. In most states it is registered or filed with the court and enforced like a judgment: a garnishee order on the business’s bank account or money owed to it, seizure and sale of property, or an examination where the business must answer questions about its finances.
Tribunals do not collect the money for you. In NSW, Victoria, Queensland, the ACT and the NT, an unpaid tribunal money order is first registered, recorded or filed with a court. In WA, SA and Tasmania the Magistrates Court decides the claim, so you already have a court judgment. Then you apply for the court’s enforcement tools.
| State | How the order becomes enforceable | Garnishee: bank account and wages | Other options |
|---|---|---|---|
| NSW | Get a certified copy of the NCAT order (no fee) and register it with the Local Court (filing fee applies) | Yes: Form 69 with Form 70 (bank) or Form 71 (wages); no filing fee | Writ for the levy of property (Forms 65, 66); examination notice (Form 51 or 52) |
| VIC | Ask VCAT to have the order recorded at the Magistrates’ Court | Yes: attachment of debt (Form 71A or 71B); attachment of earnings (Forms 72A, 72B, with a hearing) | Warrant to seize property (Form 68A); oral examination (Form 67A); instalment order |
| QLD | File the QCAT order and an affidavit with a court (the Magistrates Court up to $150,000) within six years; free | Yes: enforcement warrant for redirection of debt (Form 76 or 77) or of earnings (Form 78), with Forms 9 and 74 | Seizure and sale (Form 75); enforcement hearing |
| ACT | File the sealed ACAT order and an affidavit in the Magistrates Court, serve Form 2.49, wait 7 days | Yes: debt redirection (Form 2.62 or 2.63); earnings redirection (Form 2.64) | Seizure and sale (Form 2.59); enforcement hearing (Forms 2.50, 2.51) |
| NT | Register the NTCAT order with the Local Court (certified copy and affidavit; no fee) | Yes: attachment of debts order; attachment of earnings order with a protected earnings rate | Warrant of seizure and sale; examination summons; charging order |
| WA | Already a court judgment; apply with Form 6 and the fee | Yes: debt appropriation order (Form 6, Form 2 affidavit); earnings appropriation order (individuals only, after an instalment order is broken) | Property (seizure and sale) order; means inquiry |
| SA | Already a court judgment; start through CourtSA, Enforcement tab | Yes: garnishee order (draft Form 148); wages protected to 90% of the weekly national minimum wage | Warrant of sale (Form 163); investigation or examination summons |
| TAS | Already a court judgment; file enforcement process at the registry ($49) | Yes: provisional, then final, garnishee order attaching a debt or earnings | Warrant to sell property; judgment summons and oral examination |
Questions people ask
How long does an insurer have to decide my claim?
Four months from receiving your claim, under the General Insurance Code of Practice. The limit is 12 months only in listed situations, such as an extraordinary catastrophe, suspected fraud, or you not answering reasonable requests. Once the insurer has all the information it needs, it must decide within 10 business days. If it misses the deadline it must tell you about its complaints process.
My insurance claim was denied. What can I do?
Ask for the written reasons and copies of any reports the insurer relied on; it must give reports within 10 business days of your request. Check the policy wording, then make a complaint. The insurer must decide it within 30 calendar days. If you are still unhappy, take it to AFCA, which can require the insurer to meet the claim.
What does “utmost good faith” mean for my insurance claim?
It is a duty in every insurance contract, under s 13 of the Insurance Contracts Act, for both you and the insurer to act with the utmost good faith. For insurers it covers handling and settling claims fairly and promptly. An insurer that breaches it contravenes the Act and can face a civil penalty, and it cannot rely on a policy term in bad faith.
Can I go to AFCA if my insurer is taking too long?
Yes. Under the Code you can take your complaint to AFCA at any time and if the insurer has not resolved it within 30 calendar days. AFCA may send it back if it has not been through the insurer’s complaints process, so complain to the insurer first. AFCA covers delays in making a decision as well as denials.
The insurer’s offer is too low. How do I dispute it?
Get independent quotes or valuations and ask for the insurer’s scope of works and reports. Put the difference in writing as a complaint. AFCA considers disputes about the value of an assessed loss. Our insurance complaint sets out your figures, the policy and the law, and is ready for AFCA if the insurer does not move.
Can an insurer refuse my claim because I broke a policy condition?
Not always. Under s 54 of the Insurance Contracts Act, if you can show that something you did or failed to do after the policy started did not cause or contribute to the loss, the insurer cannot refuse the claim because of it. It can only reduce the payment to reflect any real prejudice it suffered. If the act could have caused the loss, the rules are different.
Do I get interest if my insurer paid late?
Often, yes. Section 57 of the Insurance Contracts Act makes an insurer that is liable to pay a claim also pay interest from the day it became unreasonable to withhold the payment, at a rate set by regulations. Ask for interest in your complaint and in any AFCA claim.
Should I accept a cash settlement for my home insurance claim?
Only after you check it covers the real cost of the work. Under the Code the insurer must explain how cash settlements work and how the amount was reached. Get independent builder quotes for the same scope. If the offer is too low, dispute it in writing before you sign anything that releases the insurer.
Is AFCA free for insurance complaints?
Yes. AFCA’s service is free for consumers. It covers most general and life insurance, such as home and contents, car, travel, pet, landlord and income protection. It does not cover private health insurance, which goes to the Private Health Insurance Ombudsman, or workers compensation. If you accept an AFCA determination, the insurer must comply.
How long do I have to complain to AFCA about an insurer?
Six years from when you became aware of the loss, or two years from the insurer’s final response to your complaint, whichever comes first. AFCA can extend this in special circumstances. Start sooner: evidence about damage and its cause is easier to prove while it is fresh.
Can I claim compensation for stress caused by my insurer?
Through AFCA, in limited amounts. AFCA can award compensation for non-financial loss, such as an unusual amount of physical inconvenience, up to $6,300 per claim. Financial loss you can prove, such as temporary accommodation or extra repair costs from delay, is claimed separately. Our insurance complaint ($97) itemises both.
Do I need a lawyer for an insurance dispute?
Not usually. AFCA is free and built for people without lawyers, and the Code requires insurers to explain their decisions. A clear complaint with the policy, your evidence and the amount is the key. For total losses, large business claims, life insurance or disputes about non-disclosure, consider legal advice or a free community legal centre.
Sources
- Insurance Contracts Act 1984 (compilation in force from 1 March 2024), ss 13, 14, 14A, 54, 57
- General Insurance Code of Practice 2020 (October 2023 update), paras 68-82, 146-157, 161; Insurance Council of Australia: Code of Practice
- AFCA: Insurance complaints; How we resolve complaints and our Rules; The process we follow
- ASIC Act 2001, ss 12BAA, 12BAB, 12DA
- Competition and Consumer Act 2010, Schedule 2 (Australian Consumer Law), s 63
- Tribunal and court pages listed in the table above
More guides for other businesses: how to get your money back.
Checked 19 October 2026 by the Claim Done legal content team.
Claim Done is not a law firm and does not give legal advice. This page is general information. For a complex or high-value matter, speak to a lawyer or a free community legal centre.