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.
Pet insurance has the second-highest denial rate in Australian general insurance. It also has one of the most consumer-favourable AFCA records — when policyholders push back formally, they win or partly win at very high rates.
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. Upload the policy, the vet invoice, the denial letter. AI drafts the Letter of Demand citing the right ICA sections and Code clauses. Flat $79, PDF the same day.
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, binding, and AFCA’s approach to pet insurance disputes consistently favours pet owners with documented evidence.