Most home insurance complaints are about delays, communication, expert reports, and repair scope. You can dramatically improve your outcome by tightening how you document the problem, what you ask for, and how you keep the complaint open until the outcome is actually delivered.
The internal complaints process matters because it triggers enforceable timeframes and forces the insurer to put its position in writing, especially for disputes about declined claims, claim value, or financial hardship.
If you feel like your complaint hasn’t been resolved, AFCA is a free external dispute resolution service for consumers. AFCA decisions are generally binding on the financial firm if you choose to accept the AFCA determination. If you don’t agree with the determination, you still keep your legal rights and may be able to pursue legal options.
A complaint is a process, not a fight
The regulatory framework for complaints uses a broad definition. If you express dissatisfaction about how a claim is being handled and expect a response or action, that is considered a complaint. You do not need special wording or legal language to trigger the complaints process. Insurers are expected to recognise complaints when they arise and deal with them properly.
In practice, many people hesitate to complain because they worry it will escalate conflict. In reality, the complaints process exists to resolve problems that cannot be fixed through normal claim handling.
That said, it is still best to put complaints in writing.
Phone conversations can be misunderstood, recorded poorly, or simply forgotten. A short email that clearly states that you are making a complaint removes ambiguity and ensures the issue is formally recorded and reviewed.
Complaint Timeframes
The insurer’s complaints team must investigate the issue and provide a written response. In most home insurance matters, the expected timeframe for this response is within 30 calendar days.
This response should clearly explain:
- The outcome of the complaint
- The reasons for the decision
- Any actions the insurer will take to resolve the issue
- Your right to escalate the complaint to AFCA if you are not satisfied
If the insurer needs more time in limited circumstances, they should explain why the delay is necessary and when you can expect an outcome.
What if the insurer does not respond?
If the insurer does not resolve the complaint or fails to respond within the expected timeframe, you are generally entitled to escalate the matter externally.
This usually means lodging a complaint with the Australian Financial Complaints Authority (AFCA).
At that point, the dispute moves outside the insurer and into an independent review process.
Practical tips
When you lodge a complaint:
- Clearly label it as a complaint
- Keep a copy of the email or letter
- Note the date it was submitted
- Keep records of any responses
This makes it easier to demonstrate when the timeframe started and whether the insurer has responded appropriately.
Structured complaints with clear records tend to move faster and are easier to escalate if the issue is not resolved.
You can also make a complaint to ASIC or the Code Governance Committee if the insurer breaches their regulatory obligations.
How the internal complaint process should work, and how to avoid “early closure” traps
The IDR team is typically separate from the claims team that made the original decision. Their role is to review the issue, consider the information available, and determine the company’s final position on the complaint. While they may operate independently from the frontline claims staff, it is important to understand that they are still part of the same insurer. Their role is not to act as an external referee, but to review the matter on behalf of the company and decide whether the original handling or decision should be changed.
In practice, many IDR teams also have limited delegation to overturn decisions that were made within the claims department. This means their ability to change the outcome can sometimes be constrained by internal authority limits or company positions that have already been set. As a result, a significant number of complaints are ultimately maintained rather than overturned, particularly where the issue relates to policy interpretation or reliance on expert reports.
A common issue in claim disputes is complaints being closed before the underlying problem is actually resolved.
This usually happens when a consumer raises a genuine concern and the insurer responds quickly by offering a process step, such as arranging another inspection, obtaining another expert report, or saying they will review the claim. While these steps may be useful, they do not necessarily resolve the complaint.
It is important to separate two different things. A proposed next step is simply part of the investigation process. For example, arranging another inspection or asking an expert to reconsider their report. A resolved complaint means the insurer has actually addressed the issue and committed to a clear outcome. This could include confirming that an item will be included in the claim, issuing an updated scope of works, agreeing to additional payment, or overturning a decision.
A complaint should not be considered resolved simply because the insurer has said they will take another step. The issue is only resolved when the outcome you raised the complaint about has been properly addressed.
In some circumstances, if a complaint is resolved very quickly and the customer is satisfied with the outcome, the insurer may not need to provide a detailed written response. This concept only applies where the issue is genuinely resolved and the customer is satisfied with the outcome. It does not generally apply to more complex complaints, such as disputes about declined claims, disagreements about the value of a claim, or complaints involving financial hardship.
A useful rule of thumb is this. If the insurer is only offering a process step, such as another report or inspection, keep the complaint open. If the insurer is offering a clear outcome, such as confirming payment, amending the scope of works, or overturning a decision, it may be reasonable to close the complaint once that outcome is confirmed in writing.
If an insurer tries to close the complaint too early, it is reasonable to respond clearly. For example:
“Thank you for arranging a further assessment. However, this does not resolve my complaint. Please keep the complaint open until the assessment has been completed and my requested outcome is confirmed in writing, including any updated scope of works or payment decision.” It is worth noting that some insurers actually enforce the closure of the complaint in these circumstances. However, as a consumer you can reject that this resolves your complaint and make a complaint to AFCA.
Although insurers are expected to recognise complaints when customers express dissatisfaction, it is still helpful to label your communication clearly. Starting an email with a statement such as “This is a complaint” reduces the risk that your issue is treated as a routine customer service interaction rather than being handled through the insurer’s formal complaints process.
How to Structure a Strong Complaint
This starts with keeping a clear record of events. Write down the key dates, who you spoke to, what was discussed, and what was promised. If the dispute later progresses to an external review, a clean timeline becomes one of the most important pieces of evidence. It allows the reviewer to quickly understand what happened, when it happened, and how the claim was handled over time.
Your complaint should also be factual and structured. It is reasonable to be firm, but the key points should be easy to follow. Decision makers work best with clear chronology, specific issues in dispute, and a clear request for the outcome you are seeking. When important points are buried in long or emotional explanations, they are easier to overlook.
Be clear about the outcome you want. Many complaints simply explain the problem but never state what resolution the customer is asking for. This makes it harder for the complaint handler to resolve the issue. If you want the decision reviewed, the scope of works amended, additional damage included, or payment made, say so clearly. A complaint should not only describe the issue but also identify the result you are seeking.
Objective evidence is critical wherever it is available. Photographs, videos, invoices, and contractor quotes can all help demonstrate what happened and how the damage occurred. For example, if the dispute is whether damage was caused by a sudden event or by wear and tear, evidence showing the condition before and after the event can be very important. Documentation that shows when repairs were required or when the damage first appeared can also help establish the timeline.
It is also common for insurers to rely on reports prepared by experts such as engineers, builders, hygienists, or loss adjusters. These experts may regularly perform work for insurers. This does not automatically mean their conclusions are incorrect, but their reports should still be examined carefully.
Rather than treating the report as final, it can be helpful to test how the conclusions were reached. Look at what the expert actually observed, what assumptions were made, and what information they relied on. It is also useful to consider what instructions they were given before they attended the property.
The wording used in an expert report can also be very important. Expressions such as likely, assumed, suspect, possible, probable, appears, or consistent with often indicate that the opinion is not a direct finding of fact, but an inference drawn from limited information. That does not necessarily make the opinion wrong, but it does mean the conclusion should be tested carefully. Where a report uses conditional or speculative language, it may be open to argue that the conclusion is not definitive and that the insurer cannot rely on it as though it were established fact. In those circumstances, it is reasonable to ask what objective evidence supports the opinion, whether alternative explanations were properly considered, and whether the expert can identify the observations, testing, or data that justify moving from assumption to conclusion.
A practical way to challenge an expert report without turning the dispute into a personal argument is to ask clear questions about the reasoning behind the report. For example, you might ask which parts of the report are based on direct observations and which parts are assumptions, what information the expert was provided before attending, and whether they were asked to test alternative explanations for the damage or only to confirm a particular theory.
Approaching the issue this way keeps the discussion focused on evidence and reasoning. Complaints that are supported by a clear timeline, structured explanation, objective evidence, and a clearly stated outcome are much easier for complaint handlers or external reviewers to assess.
What if the complaint is not resolved through Internal Dispute Resolution?
AFCA is an independent external dispute resolution scheme that reviews complaints about financial firms, including insurers. It provides a free process for consumers to have disputes reviewed outside the insurer.
Escalating a complaint to AFCA does not mean the dispute immediately moves to a formal decision. The first stage is usually registration and referral. When a complaint is lodged, AFCA typically sends the complaint back to the insurer for another opportunity to resolve the issue.
This stage is more important than many people realise. A significant number of disputes are resolved at this point. In practice, around half of complaints are resolved after AFCA registers the dispute and refers it back to the insurer.
There are several reasons for this. Once a complaint is lodged with AFCA:
- The dispute is now visible to an external regulator-approved body.
- The insurer must formally respond through the AFCA process.
- The complaint is being monitored externally.
For insurers, resolving a complaint early can often be quicker and less costly than allowing the dispute to proceed through the full AFCA investigation process. As a result, this stage often prompts a more careful review of the claim and sometimes leads to a different outcome.
If the matter is not resolved during the referral stage, the complaint moves into AFCA case management. At that point AFCA will begin gathering information from both sides, reviewing the evidence, and facilitating discussions between the parties. Many disputes resolve during this phase through negotiation or conciliation.
If an agreement still cannot be reached, AFCA may issue a preliminary view explaining how it is likely to decide the case based on the evidence available. This often prompts further settlement discussions.
If the dispute remains unresolved after that point, AFCA can issue a formal determination. If the consumer accepts the determination, it becomes binding on the insurer.
The key point for consumers is that escalation is not the end of the process. In many cases, lodging the complaint externally is the step that prompts the insurer to reassess the claim more carefully and resolve the dispute.
Consumers who want to better understand the external dispute process can also review the guidance published on the AFCA website. AFCA provides clear information explaining how complaints are lodged, what types of disputes it can consider, and how the process works once a complaint is registered. The material outlines the key stages of the process, including referral back to the financial firm, case management, negotiation or conciliation, and potential outcomes such as preliminary assessments or formal determinations. AFCA also publishes practical guides and consumer resources that explain the process in plain language. Importantly, AFCA’s service is free for consumers and is designed to provide an independent alternative to court for resolving disputes with financial firms, including insurers.
You can access AFCA’s consumer guides and publications here:
https://www.afca.org.au/about-afca/publications
Understanding AFCA Determinations and Your Options
If a complaint cannot be resolved through negotiation or case management, AFCA may issue a formal determination. This is the final stage of the AFCA process and represents AFCA’s written decision on the dispute based on the evidence and submissions provided by both parties.
A determination will explain AFCA’s findings, how it interpreted the policy and the evidence, and what outcome it believes is fair in the circumstances. This might include requiring the insurer to pay the claim, vary the settlement amount, take certain actions, or confirming that the insurer’s decision was reasonable.
What many consumers do not realise is that an AFCA determination creates an important decision point.
If you accept the determination, it becomes binding on the insurer. The insurer must comply with the outcome set out in the determination. However, acceptance also means the dispute is considered finalised. In most cases you will no longer be able to pursue the same dispute against the insurer through the courts.
If you do not accept the determination, it is not binding on you. The complaint will be closed by AFCA and you retain the option to pursue the matter through other avenues, such as court proceedings.
Because of this, it is important to carefully consider your position before accepting a determination. You should take time to review:
- The reasoning in the determination
- Whether all relevant evidence was considered
- Whether the outcome reflects the loss you have suffered
- Whether there are other legal or strategic options available
For some consumers, accepting the determination provides a quicker and practical resolution. For others, particularly where the claim value is significant or the reasoning is disputed, it may be worth obtaining advice before deciding whether to accept it.
The key point is that accepting an AFCA determination is not just acknowledging the outcome. It is a decision that can limit your ability to challenge the insurer further, so it should be considered carefully before you confirm acceptance.
Why documentation and timelines matter
In claim disputes, documentation often becomes the difference between a complaint that is persuasive and one that is difficult to assess. When a disagreement develops about how a claim was handled, the discussion usually turns to what happened, when it happened, and what was said or promised at each stage of the process.
Timelines play an important role in this. A clear chronology helps decision makers understand the sequence of events and whether the claim was handled reasonably. It also helps demonstrate issues such as delays, missed inspections, changing explanations for a decision, or steps that were taken by the insurer after the claim was lodged.
Missing records can undermine a complaint, even where the consumer’s position is correct. Without dates, emails, photos, or written notes, it can become difficult to show exactly what occurred or to challenge a different version of events. In many disputes, the credibility of the explanation depends heavily on whether the events are supported by contemporaneous records.
External dispute bodies such as AFCA rely heavily on documented chronology when reviewing complaints. A well-organised timeline allows the reviewer to quickly understand how the claim progressed, what evidence was considered, and whether the insurer responded appropriately at each stage.
For this reason, it is helpful to start keeping records early in the claim process, even before a dispute develops. A simple timeline can be enough. Record the date of key events, who you spoke to, what was discussed, and any commitments that were made. Keep copies of emails, letters, reports, and photographs relating to the claim.
By the time a complaint needs to be reviewed internally or externally, a clear timeline supported by documents provides a strong foundation for explaining the issue and demonstrating how the claim was handled over time.
Why expert reports often become the central battleground
In many home insurance disputes, the key issue is not the wording of the policy but the insurer’s view about what caused the damage. This is why expert reports often become the central point of disagreement in a claim.
Insurers frequently rely on reports prepared by engineers, builders, hygienists, loss adjusters, or other specialists when deciding whether to accept or decline a claim. These reports are intended to explain the cause of the damage and whether it falls within the events covered by the policy. Once an expert report reaches a particular conclusion, it can strongly influence the insurer’s decision.
For example, if a report concludes that damage was caused by wear and tear, maintenance issues, or gradual deterioration, the insurer may rely on that opinion to decline the claim. If the report concludes that the damage was caused by a sudden insured event, such as a storm or escape of liquid, the claim may instead be accepted.
Because of this, the expert’s opinion often shapes the entire decision pathway. In practice, many disputes turn on how the expert framed the cause of the damage and the assumptions they relied upon in reaching that conclusion.
This is why claim disputes are often less about the policy wording itself and more about the factual question of what actually happened. The policy may provide cover for certain events and exclude others, but the expert’s view about the cause of the damage determines which part of the policy the insurer relies on.
For consumers, it is important to understand that expert reports are not simply administrative documents. They are often the foundation of the insurer’s reasoning. If a dispute arises, the report should be reviewed carefully to understand what the expert observed, what assumptions were made, and how the conclusions were reached. In many cases, examining the reasoning behind the report becomes one of the most important steps in challenging a claim decision.
Why Independent Expert Evidence Matters
In many home insurance disputes, the outcome ultimately turns on expert evidence. Insurers frequently rely on reports prepared by engineers, builders, hygienists, loss adjusters, or other specialists to support their decisions. These reports often form the foundation of a decline, a reduced scope of works, or a limitation on what damage will be accepted.
Because of this, the evidence contained in expert reports can carry significant weight in both complaints and external dispute resolution processes.
Insurer-appointed experts are not necessarily incorrect, but they are usually engaged by the insurer and may regularly perform work for that insurer. This means their report is prepared within the insurer’s claims process and often based on the instructions they were given. Those instructions can influence the scope of the inspection and the issues the expert is asked to consider.
Independent expert evidence can therefore play an important role in balancing the information available in a dispute.
An independent expert may:
- Inspect the damage without relying on the insurer’s assumptions
- Consider alternative causes of the damage
- Review whether the insurer’s expert report has gaps or unsupported conclusions
- Provide a second opinion on causation, scope of damage, or required repairs
This can be particularly important in disputes involving issues such as:
- Whether damage was caused by a sudden insured event or gradual deterioration
- Whether mould or water damage is linked to an insured event
- Whether the scope of repairs proposed by the insurer is sufficient
- Whether the insurer’s expert properly investigated all possible causes
Independent evidence is often influential because it introduces another professional opinion that must be considered. When two qualified experts disagree, the reasoning behind each opinion becomes important. Decision makers will look closely at which report is better supported by observations, testing, photographs, and clear explanations.
Independent reports can also help identify weaknesses in existing reports. For example, they may highlight where conclusions were based on assumptions rather than direct observations, where key areas were not inspected, or where alternative causes were not considered.
For consumers, the key point is that expert reports should not be treated as final or unquestionable simply because they were commissioned by the insurer. If the conclusions appear incomplete or inconsistent with what you observed, obtaining independent advice or evidence may help clarify the issue.
In many claim disputes, strong independent evidence can be the difference between a claim remaining declined and a claim being reconsidered.
Requesting reports, file notes, and your personal information
If you are challenging an insurer’s decision, it is important that you have access to the same information the insurer relied on. Without seeing the reports, file notes, and other records used to assess the claim, it is difficult to properly understand or respond to the insurer’s reasoning.
In many claim disputes, the insurer’s position is based on internal notes, expert reports, photographs, and instructions given to assessors or other service providers. These materials often explain how the insurer reached its conclusion and what evidence it relied upon.
You are generally entitled to request access to your personal information held by the insurer under the Privacy Act 1988, including information contained in reports, claim file notes, internal communications, and decision records. The General Insurance Code of Practice also requires insurers to provide customers with copies of information and reports relied upon in assessing a claim when requested.
When requesting information, it is helpful to be specific about the documents you want. This reduces the risk of receiving only a partial response and helps ensure you receive the key records that were used in assessing the claim.
Typical documents to request include:
- All expert, assessor, investigator, loss adjuster, and service supplier reports
- Photographs, inspection notes, measurements, and scopes of works
- Claim file notes and internal decision records
- Communications and instructions provided to experts or service suppliers
- Call recordings or transcripts relating to the claim and any complaints
Having these materials allows you to review the insurer’s evidence, understand the reasoning behind the decision, and identify any gaps or assumptions that may need to be challenged.
Sample wording you can use
Subject: Request for claim documents and personal information (Claim number: [insert])
Hi [Name],
I request access to my personal information held by you in relation to this claim under Australian Privacy Principle 12 of the Privacy Act 1988 (Cth).
I also request copies of all information and reports relied upon in assessing my claim in accordance with the General Insurance Code of Practice.
Please provide copies of the following:
- All expert, assessor, investigator, loss adjuster, and service supplier reports (including any updated versions)
- Photographs, inspection notes, measurements, and scopes of works
- Claim file notes and internal decision records
- Communications and instructions provided to experts or service suppliers that relate to my claim assessment
- Call recordings and transcripts that relate to my claim and complaint
If access to any of this material is refused, please confirm the specific reason for refusal and the legal or policy basis relied upon in writing.
Kind regards,
[Name]
The emotional toll of claim disputes
Home insurance disputes are rarely just administrative problems. For many homeowners, they occur at the same time they are dealing with significant disruption to their home and daily life. Damage to a property can mean living in unsafe conditions, managing temporary accommodation, or dealing with ongoing repair uncertainty while the claim is being assessed.
Disputes can also take time to resolve. Complaints and external reviews may run for months, and in some cases longer. During that period, homeowners are often trying to manage repairs, organise quotes, communicate with contractors, and respond to insurer requests while also navigating complex claim discussions.
The technical nature of insurance disputes can add to this pressure. Expert reports, engineering opinions, policy definitions, and regulatory processes can be difficult to interpret without experience in the claims process. Many homeowners find themselves trying to understand highly technical reports or policy wording while also managing the practical impact of the damage to their home.
For this reason, it is important to recognise that you do not need to navigate the process alone. If the situation is becoming overwhelming, it is reasonable to seek assistance from a trusted adviser, advocate, or professional who understands the claims process.
It is also important to understand that insurers have specific obligations when a customer is experiencing vulnerability. The General Insurance Code of Practice requires insurers to take extra care when dealing with customers who are experiencing vulnerability due to factors such as illness, disability, financial hardship, family violence, or other circumstances that may make it more difficult to manage the claim process.
If you inform your insurer that you are experiencing vulnerability, they are expected to take reasonable steps to provide additional support. This may include adjusting communication methods, allowing more time for information to be provided, prioritising aspects of the claim that affect health or safety, or considering practical solutions to reduce the stress of the situation.
Letting the insurer know about your circumstances can help ensure the claim is handled in a way that recognises the challenges you are facing while the dispute is being resolved.
Seek Assistance
Insurance claim disputes can become stressful and highly technical, particularly when the disagreement involves expert reports, policy interpretation, or allegations about maintenance, wear and tear, or causation. Many consumers start the process expecting a straightforward discussion about damage, only to find themselves dealing with complex reports, regulatory processes, and lengthy correspondence.
It is also common for disputes to take time to resolve. Complaints may involve multiple inspections, competing expert opinions, and formal review processes. For homeowners who are already dealing with property damage, temporary accommodation, or financial pressure, managing this process on top of everything else can feel overwhelming.
If you find the process difficult to navigate, it is reasonable to seek assistance. Independent advice can help you understand the insurer’s reasoning, identify weaknesses in the evidence relied upon, and structure your complaint or escalation more effectively.
Claims Hero offers a free initial consultation. If you have received a decline, a partial denial, or are unsure whether the insurer’s position is correct, our team can review the decision, the policy wording, and the available evidence to help you understand your options. In many cases, a structured second review can identify issues that may not be obvious when you are dealing with the claim alone.
Templates you can copy and send
Template complaint email to the insurer
Subject: Formal complaint about my home claim (Claim number: [insert])
“Hi [Name],
This is a complaint about the handling of my claim. I would like to raise the following concerns:
- Issue(s): 1. [One sentence, what is wrong]
- 2. [One sentence, what is wrong]
The following timeline is relevant to the issues raised above:
- [Date]: [event]
- [Date]: [event]
- [Date]: [event]
The following evidence supports my complaint:
- [insert relevant evidence you’re relying on]
Requested Outcome
In resolution of my complaint, I request the following
- [Clear outcome, for example updated scope including X, or payment of $Y, or a new inspection by a suitably qualified expert, plus a written decision]
I consider the resolution is reasonable on the following basis:
- [insert reasoning – ensure this is factual and avoid emotive language]
Please confirm you have recorded this as a complaint and advise the name and contact details of the person assigned to handle it.
Kind regards,
[Name]”
Disclaimer
This article is general information only. It is not legal advice, financial advice, or a substitute for professional advice tailored to your circumstances.
We have not considered your personal objectives, financial situation, needs, or claim details. You should consider obtaining independent advice before acting on the information in this article.
For privacy reasons, any examples and templates are generic and should be adapted carefully to your situation.