The roof leaks during the storm. Ceilings come down. A tree drops on the carport. You photograph everything, lodge the claim, get an assessor visit — and weeks later the report comes back: “The damage is consistent with long-term wear and pre-existing maintenance issues. Claim declined.” The repair quote is $28,000. You’re staring at a tarp on your roof and a wall of insurer jargon.
This is one of the most common refusal patterns in Australian home insurance, and one of the most successfully overturned at AFCA. Here’s how to turn it around.
The legal framework
Home and contents policies are governed by the Insurance Contracts Act 1984 (Cth) and the General Insurance Code of Practice. Insurers cannot exclude storm damage simply because the roof was older — they must prove the damage would have occurred even without the storm event. The doctrine of “proximate cause” matters: if the storm was the dominant cause, the claim is payable even if pre-existing condition was a contributing factor. AFCA applies this test consistently.
Common defences and where they fall apart
- “Lack of maintenance” exclusion. Insurer must prove a reasonable homeowner would have detected and fixed the issue. Most don’t meet that bar.
- “Wear and tear” exclusion. Only excludes the worn item itself, not consequential damage. A worn flashing that lets a storm in still triggers cover for the water damage.
- “Not a storm” — wind speed too low. Bureau of Meteorology records often show otherwise. Pull the data for your postcode and date.
- “Single event” technicalities. Insurer tries to split one event into multiple to apply excess multiple times — usually not contractually supported.
- Desktop assessment only. Section 13 utmost-good-faith duty arguably requires a physical inspection for claims of this size.
Ready to put it in writing?
Answer 3 quick questions to check you have the details your document needs, and see your next step.
1. Who is this about?
2. How much is at stake?
3. Do you have it in writing?
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What the document does
The Letter of Demand puts your insurer on formal notice citing the policy number, the specific exclusion they’re relying on, why it doesn’t apply on the facts, the BOM data or independent builder report supporting you, the dollar amount, and a 21-day deadline. It also flags the AFCA jurisdiction — which insurers want to avoid because AFCA awards costs and interest.
What Claim Done delivers
Ten-minute wizard, flat $97 fee. Your demand letter is drafted by our Programmatic Algorithms using Australian insurance law, cites the right ICA sections and Code clauses, and arrives in your dashboard as a polished PDF. Add an independent builder’s report (anywhere from $300 to $800) and your case is materially stronger.
What to expect after sending
Insurers usually respond within 21 days with either a revised assessment, a settlement offer, or a request for further information. If they hold firm, lodge with AFCA — free for you, and its decisions can bind the insurer. Your Letter of Demand becomes Exhibit A.
What happens when you put it in writing — properly
Same problem. What a prepared case looks like.