Disputing a declined roof claim: internal complaints, AFCA and the evidence that works

If your insurer declines or underpays a roof claim, first make a formal complaint to the insurer (internal dispute resolution), which must generally respond within 30 calendar days under ASIC's rules. If you are unhappy with the response, or it is late, you can take the dispute to the Australian Financial Complaints Authority (AFCA), a free, independent ombudsman scheme for disputes with insurers and other financial firms. Your case is strongest with independent evidence: dated storm data and photos, an independent roofer's or building consultant's report that addresses the cause of damage, and the insurer's own assessment report. AFCA looks at the policy, the law, the General Insurance Code of Practice and what is fair in the circumstances.

This guide is part of roofing problems and where to get help. It is general information, not legal advice.

Step 1: understand the decision

Ask the insurer, in writing, for:

• The decision and the reasons, citing the policy clauses relied on
• Copies of the assessor's, builder's or engineer's reports used to decide the claim
• Any photos taken during the assessment

Under the General Insurance Code of Practice, insurers must give reasons for declining a claim and tell you how to obtain the information relied on. If information is withheld, ask why.

Step 2: build your evidence

An expert report is most useful when it responds directly to the insurer's reasons, for example explaining why cracking patterns are consistent with hail impact rather than age.

Step 3: internal complaint

Write to the insurer's complaints team, not just the claims officer. Include:

1. Your policy and claim numbers
2. What you disagree with and why
3. The outcome you want (for example, acceptance of the full claim, or payment of a specific amount)
4. Your evidence as attachments

Under ASIC Regulatory Guide 271, financial firms generally must give a final response to a standard complaint within 30 calendar days. Keep a note of the date you lodged it.

Step 4: AFCA

You can lodge with AFCA online or by phone. Key points:

• Free for consumers.
• You usually need to have complained to the insurer first; AFCA will refer it back if you have not.
• There are time limits. Generally, you must lodge within two years of the insurer's final response. Check AFCA's current rules.
• AFCA may try to resolve the complaint by negotiation or conciliation first, then make a preliminary assessment, and finally a determination.
• A determination binds the insurer if you accept it. If you do not accept it, you keep your right to go to court.
• AFCA has compensation limits for general insurance disputes, which are adjusted periodically; check the current figures on AFCA's site.

Worked example (illustrative)

After a severe storm, an insurer declines a claim for a damaged tile roof, citing "wear and tear: deteriorated ridge pointing". The homeowner:

1. Requests the assessor's report and finds it notes "displaced ridge capping on the north side" with no photos of the pointing before the storm.
2. Obtains a Bureau of Meteorology record of strong wind gusts in the area on the day.
3. Finds real estate photos from 18 months earlier showing intact ridge capping.
4. Commissions a building consultant's report for an illustrative $800 that concludes the displacement pattern is consistent with wind uplift.
5. Lodges an internal complaint with this evidence asking for $12,400 (the cost of the repair quote).
6. The insurer offers $6,000. The homeowner takes the complaint to AFCA, which reviews the evidence and either facilitates a settlement or decides the matter.

The outcome depends on the evidence and the policy wording; this example shows the process, not a predicted result.

Common reasons roof claims are declined

• Damage attributed to wear and tear, rust or gradual deterioration
• Lack of maintenance, such as blocked gutters
• Faulty workmanship from earlier roof work
• No insured event identified on the date
• Non-disclosure of known defects when the policy was taken out or renewed
• Policy exclusions such as specific storm-surge or flood limitations

Tips for a smoother dispute

• Stay factual and polite in writing.
• Respond to the insurer's specific reasons rather than general unfairness.
• Do not let the repair contractor be your only expert; insurers and AFCA give more weight to independent reports.
• If you are experiencing financial hardship or vulnerability, tell the insurer; the Code has provisions for customers in these situations.
• Ask about a cash settlement if repair is delayed, and get your own quotes before accepting.

Frequently asked questions

Can I go straight to AFCA?

AFCA usually requires the insurer to have had a chance to resolve the complaint first, but you can contact AFCA early for guidance.

Do I need a lawyer for AFCA?

No. Many people lodge AFCA complaints themselves. Free legal help may be available through community legal centres or specialist services after disasters.

What if the claim was handled by my strata's insurer?

If your roof is common property, the owners corporation is usually the policyholder. Work through the strata manager; the owners corporation may be the party that complains to AFCA.

Does a catastrophe declaration help?

An Insurance Council catastrophe declaration prioritises claims from the event and can change some timeframes. It does not change whether your policy covers the damage.

Sources

• Australian Financial Complaints Authority — lodging complaints, time limits and compensation caps
• ASIC — Regulatory Guide 271 on internal dispute resolution
• Insurance Council of Australia — General Insurance Code of Practice
• Bureau of Meteorology — weather observations and storm records
• Moneysmart (ASIC) — making an insurance complaint