A homeowner has won a $631,500 payout – the most allowed under dispute laws – after “methodically” proving his roof damage was accidental as defined by his policy with QBE.

The man lodged his claim on July 1 last year after discovering several metal nail plates connecting timber roof trusses were dislodged, and sagging on the ceiling below. The damage occurred after he had an air-conditioning unit installed in the roof space.

QBE initially declined the claim based on its engineer’s report blaming wear and tear and gradual deterioration. The report said the cause was “nail plate backout”, a well-known construction issue, but the Australian Financial Complaints Authority says it did not provide compelling reasons to support this conclusion.

The homeowner engaged engineers who blamed overloading from the air-con installation.

QBE later reassessed and agreed the installation was a partial cause, but it still rejected the claim, saying the damage was not accidental and it fell under a faulty workmanship and renovation exclusion.

It said the damage was not the result of a mishap or an unfortunate accident; and the damage was the direct result of the air-con installer’s failure to adhere to structure guidelines.  

But AFCA objects to QBE’s interpretation. “Clearly, something adverse happened here (ie overloading), which the complainant did not expect, resulting in roof damage,” the authority said in a dispute ruling. “The information available shows this damage was accidental and not caused by wear and tear.”

AFCA’s ombudsman says the workmanship exclusion does not apply because it requires the insurer to show the claimant “failed to fix faulty workmanship as soon as was reasonable after he became aware of it”.

The homeowner “made a claim … as soon as he became aware of the damage. He also immediately engaged an engineer to provide advice on the necessary works. I consider he did so within a reasonable time.”

QBE should have accepted the claim by February after receiving relevant reports from the homeowner, the authority says.

“The complainant has handled the complaint methodically and professionally, but this has no doubt come at a cost to him and his family.”

AFCA says the insurer should pay more than $700,000 for repairs, temporary accommodation and other losses, but the maximum the authority can award is $631,500, plus interest. It has also awarded $5000 for professional fees and $5000 for non-financial loss.

See the determination here.