Pet Insurance Claim Refused? Letter of Demand Template (Australia)

The vet bill was $4,800. You lodged the claim with your pet insurer expecting the bulk of it back. Two weeks later: declined. The reason is one of the standard three — “pre-existing condition”, “bilateral condition affecting the unaffected limb”, or “behavioural condition not covered”. You’re left with a stressed dog or cat and a bill you bought a policy specifically to cover.

The legal framework

Pet insurance is regulated under the Insurance Contracts Act 1984 (Cth) and the General Insurance Code of Practice (most pet underwriters are signatories — Hollard, Greenstone, RACQ, etc.). The Design and Distribution Obligations apply to product suitability. ASIC RG 271 sets internal-dispute timeframes.

Common refusal reasons and how to challenge them

• “Pre-existing condition.” Insurer trawls vet records for any prior visit and links it. Often the prior visit was for an unrelated symptom. Independent vet letter usually settles it.
• “Bilateral condition.” If the right hip had treatment, they exclude the left hip too. The exclusion has to be clearly disclosed in the PDS — many aren’t applied transparently.
• “Behavioural condition not covered.” Distinguish between behavioural cause and medical consequence. A cat that licks itself raw because of an allergy has a medical condition, not a behavioural one.
• “Waiting period not served.” Many policies have shorter waiting periods for accidents than illness — check.
• “Annual sub-limit reached.” Sub-limits apply per condition; sometimes insurer wrongly aggregates across conditions.

What the document does

The Letter of Demand identifies the policy, the claim, the exact denial reason, the contractual or legal flaw in that reason, the dollar amount, and a deadline. Critically, it formally requests the insurer’s reasoning under the Code — including any vet records they relied on and how they reached the “pre-existing” or “bilateral” conclusion.

What Claim Done delivers

Ten-minute wizard. Tell us about the policy, the vet invoice, the denial letter. Our Programmatic Algorithms draft your formal complaint to the insurer and your AFCA complaint citing the right ICA sections and Code clauses. Flat $97 fee, draft ready in about five minutes for you to read and approve.

What to expect after sending

Pet insurers typically respond within 21–30 days. Many reverse on receipt of an independent vet letter. If denied again, lodge with AFCA — completely free for you, and its decisions can bind the insurer.