Maintenance Exclusions: When Insurers Blame You for Normal Wear

Maintenance exclusions are clauses in insurance policies that allow insurers to deny claims for damage they say resulted from a lack of upkeep rather than a sudden insured event. However, Australian insurers must prove the maintenance issue directly caused the damage, and normal wear does not automatically invalidate a claim. If a covered event like a storm caused the damage and wear was only incidental, your claim should still be paid.

Key takeaways

• The insurer must prove the maintenance issue directly caused the damage, not merely that wear existed.
• Normal ageing of materials does not automatically void a claim if a covered event caused the damage.
• Section 54 of the Insurance Contracts Act is often relevant when insurers blame maintenance for storm or water damage.
• Request the assessor's report to see whether the maintenance finding is supported by evidence or just assumed.

Your insurer has denied your claim, pointing to a "maintenance" or "wear and tear" exclusion in your policy. You feel blindsided. The damage was caused by a storm, not by your failure to look after the property. This is one of the most common and frustrating reasons insurers give for declining claims, and it is often applied far more broadly than the policy wording actually allows.

What Are Maintenance and Wear-and-Tear Exclusions?

Most home and contents insurance policies contain an exclusion for damage caused by lack of maintenance, gradual deterioration, or normal wear and tear. The intent behind these exclusions is reasonable: insurance is designed to cover sudden and unforeseen events, not the slow decline that comes with owning a property.

However, the way insurers apply these exclusions can stretch well beyond their intended purpose. A roof that has seen 20 years of weather might still be perfectly functional until a severe storm tears tiles loose. Gutters that have accumulated some leaf litter may still handle normal rainfall but overflow during a once-in-a-decade downpour. The existence of wear does not mean wear caused the damage.

The Critical Distinction: Dominant Cause vs Contributing Factor

This is where many insurers overreach, and where your rights become important. Many Product Disclosure Statements (PDS) specify that the maintenance exclusion only applies when the lack of maintenance is the "dominant," "proximate," or "effective" cause of the loss. This is a crucial qualifier that insurers sometimes gloss over when declining a claim.

The distinction works like this:

• If your gutters were completely blocked with years of debris and water backed up into the ceiling cavity during light rain, the lack of maintenance is arguably the dominant cause. The exclusion may legitimately apply.
• If your gutters had some normal leaf accumulation but a severe storm dumped unprecedented rainfall that overwhelmed even well-maintained guttering systems in the area, the storm is the dominant cause. The leaf litter was at most a contributing factor, and the exclusion should not apply.

The same logic applies to roofing. Old roof tiles are not defective simply because they are old. If wind of sufficient force dislodges tiles that were otherwise secure and functional, the insured event (the storm) is the dominant cause of the damage. The age of the tiles is a background condition, not the proximate cause.

Section 54 of the Insurance Contracts Act 1984

Section 54 is one of the most important consumer protections in Australian insurance law. It prevents insurers from refusing to pay a claim based on an act or omission by the insured (such as alleged failure to maintain the property) unless the insurer can demonstrate that it was prejudiced by that act or omission.

In practical terms, this means an insurer cannot simply point to a maintenance issue and deny the entire claim. The insurer must show that the lack of maintenance actually caused or contributed to the specific loss being claimed. If the damage would have occurred regardless of the maintenance issue, Section 54 may protect your entitlement to payment.

For example, if a storm causes widespread roof damage across a neighbourhood and your insurer argues that your roof was not adequately maintained, Section 54 places the burden on the insurer to prove that better maintenance would have prevented the damage. If similarly maintained or even well-maintained roofs in the area suffered the same fate, this argument falls apart quickly.

How AFCA Approaches Maintenance Disputes

The Australian Financial Complaints Authority (AFCA), which handles disputes between consumers and insurers, takes a careful approach to maintenance exclusions. When reviewing these disputes, AFCA generally considers several key factors:

• Whether the insurer has provided evidence that the lack of maintenance was the dominant or proximate cause of the loss, not merely a contributing factor
• Whether the insurer obtained an expert report that specifically addresses causation, rather than simply noting pre-existing wear
• Whether the insured event (such as a storm) would have caused the same or similar damage to a reasonably maintained property
• The specific wording of the policy, including any qualifiers around the maintenance exclusion

AFCA has consistently found in favour of consumers where insurers rely on generic assessments or fail to establish a clear causal link between the alleged maintenance failure and the specific damage claimed. An assessor's report that simply notes "the roof is old" or "there is evidence of wear" is not, on its own, sufficient to invoke the exclusion. The insurer must connect the maintenance issue to the actual loss.

Practical Examples

Blocked Gutters During a Storm

A homeowner's gutters have some leaf build-up, consistent with normal accumulation between seasonal cleaning. A severe storm with heavy rainfall causes water to overflow the gutters and enter the roof cavity. The insurer denies the claim, citing the maintenance exclusion.

The key question is whether the gutters would have coped if they had been perfectly clean. If the storm intensity exceeded the capacity of clean gutters (which can be assessed by comparing rainfall data against gutter specifications), the blockage is a contributing factor at most. The storm remains the dominant cause, and the exclusion should not apply.

Old Roof Tiles Dislodged by Wind

A home has concrete roof tiles that are 25 years old. Strong winds during a storm dislodge several tiles and cause water damage to the interior. The insurer's assessor notes the age of the tiles and recommends declining the claim on the basis of wear and tear.

However, old tiles that are properly bedded and were functional before the storm were not failing due to age. They failed because of wind force. If newer tiles in the same area also suffered damage, this further supports that the storm, not the age of the tiles, was the dominant cause of the loss.

What to Do If Your Claim Is Denied on Maintenance Grounds

1. Request the insurer's full reasons for the decision in writing, including any expert reports they relied upon.
2. Check your PDS carefully. Look at the exact wording of the maintenance exclusion. Does it require maintenance failure to be the "dominant" or "proximate" cause? Many policies do, and this qualifier works in your favour.
3. Gather your own evidence. Photographs, receipts for past maintenance work, statements from tradespeople, and Bureau of Meteorology data for the event can all support your case.
4. Compare with neighbours. If other properties in your area suffered similar damage, this undermines the argument that your specific maintenance caused the loss.
5. Lodge an internal complaint with your insurer. Under the General Insurance Code of Practice, your insurer must review the decision and respond within specific timeframes.
6. If the internal complaint does not resolve the issue, lodge a complaint with AFCA at no cost. AFCA has the power to make binding decisions that insurers must follow.

How The Fair Claims Co Can Help

Disputing a maintenance exclusion denial requires careful analysis of your policy wording, the insurer's reasoning, and the available evidence. The Fair Claims Co prepares professional dispute documents and AFCA submissions that address these issues methodically, presenting your case in the framework that decision-makers expect to see. If your claim has been denied on maintenance or wear-and-tear grounds, we can help you understand your options and build a strong submission.

If your insurer has specifically cited "wear and tear" as the reason for denial, our guide to challenging wear and tear denials covers the legal distinction between gradual deterioration and damage caused by an insured event.