Insurance Dispute Settled with New Rulings

2

The issue arose when the claimant noticed a malfunction in her dishwasher as early as April of the previous year and filed a claim in September. However, Strata Community Insurance Agencies challenged the claim arguing that the damage might engage exclusions pertaining to rodent activity.

Central to this case was a tax invoice detailing observations from a visiting plumber. According to the original report, the plumber suspected damage caused by rodents chewing on the hose. Yet, the said invoice was later altered to omit this suspicion, raising further questions about motive and clarity.

Further dialogue between the plumber and the insurer's representative disclosed that changes to the invoice were requested by the policyholder. Additionally, alternative explanations surfaced, such as potential damage from consistent interaction of the hose with the access hole each time the machine was used. The plumber did not exclude the possibility of continuous friction contributing to the damage.

The insurance provider's expert, however, observed extensive damage on the hose but reported an absence of signs that typical wear and tear would leave. The expert concluded that the use of the dishwasher was unlikely to generate sufficient force to result in such severe damage. They further stated that the condition of the hose strongly indicated rodent activity as initially suggested by the plumber.

During the dispute resolution hearing, the Australian Financial Complaints Authority evaluated the matter. They acknowledged the customer's view disputing the expert judgment but emphasized her failure to present any compelling evidence to counter the presented arguments.

The authority, after reviewing the diverse perspectives and the expert observations, ruled in favor of accepting the view that rodents were probably the primary cause of the damage. While this event originally triggered policy coverage, the clauses excluding rodent damage ultimately prevailed to deny the claim.

Echoing this outcome, an ombudsman for the AFCA commented, “I am satisfied, without evidence to contrary, it is fair that the insurer be permitted to rely on the opinions provided by the appointed consultants.” This position emphasizes the criticality of providing concrete evidence when challenging an insurer's expert analysis.

This case serves as a compelling reminder for policyholders of the complexities and critical nuances involved in insurance claims, especially those involving ambiguous causes like rodent activity. It underscores the importance of detailed documentation and professional assessments when navigating through such disputes.

Published:Thursday, 7th Nov 2024
Source: Paige Estritori

Share this news item:

Insurance News

ClearView Names New Underwriting Head Amidst Strategic Changes 30 Jun 2025: Paige Estritori ASX-listed life insurer ClearView has announced the appointment of Peter Tilocca as Head of Underwriting, coinciding with key updates to its underwriting standards and definitions. Tilocca's extensive two-decade career in Australian underwriting includes leadership roles at Zurich, Noble Oak, One Path Life, and RGA Australia. His new role with ClearView commenced on 30 June. - read more

Ombudsman Supports Theft Claimant in Home Business Coverage Dispute 30 Jun 2025: Paige Estritori A recent case has seen a policyholder triumph over her insurer after the Australian Financial Complaints Authority (AFCA) ruled in her favour following a contentious dispute regarding home business operations. The controversy arose when the woman's theft claim was denied by her insurance provider, IAG, over allegations of fraudulent misrepresentation about the use of her rental property. - read more

AFCA Upholds Insurance Fraud Ruling Over Disputed Possum Accident 26 Jun 2025: Paige Estritori A motorist's claim that he crashed into a tree to avoid a possum has been denied by the Australian Financial Complaints Authority (AFCA), which supported the insurer's fraud decision. The incident involved the driver crashing his Jeep—insured for over $20,000—on a dimly-lit street, purportedly avoiding the rain-soaked motorway en route to the store. - read more

Code Watchdog Criticises Insurer for Misleading Rejection Letters 24 Jun 2025: Paige Estritori The Life Code Compliance Committee has recently reprimanded a life insurance provider for issuing misleading rejection letters to policy applicants. These letters were deemed 'ambiguous and contradictory' and failed to clearly inform applicants of their review options after being denied coverage. - read more

Insurer Ordered to Pay Full Claim for Confusing Patio Coverage 23 Jun 2025: Paige Estritori A recent ruling mandates that an insurer must fully honor a storm-related claim due to ambiguous policy wording regarding items in open areas. The Australian Financial Complaints Authority (AFCA) determined that the insurer's restriction on coverage for items in a patio area was unfounded, as the policy's phrasing was not clear. - read more

Australia Sees Dramatic Drop in Catastrophe Losses 23 Jun 2025: Paige Estritori Last year saw Australia's insured catastrophe losses plummet to just $500 million, marking the lowest level since 2004, according to Aon's latest Climate and Catastrophe Insight report. Notably, the Insurance Council of Australia reported no disasters for the year, a situation not seen since 1982. This comes in stark contrast to 2023, when disaster-related insured losses soared to over $3.6 billion. - read more