Insurance causation, wear and tear & gradual damage

Many rejected claims are described as “wear and tear” disputes when the real disagreement is about causation. The insurer may accept that damage exists but say it resulted from deterioration, poor maintenance or a pre-existing condition rather than the insured event.

The useful question is not whether some wear existed. It is whether that excluded or uninsured condition was the effective cause of the loss being claimed.

Separate three different things

1. The insured event: the storm, escape of water, accidental impact or other peril said to have occurred.
2. The background condition: age, deterioration, maintenance history or another pre-existing feature.
3. The resulting damage: the physical loss or damage for which payment, repair or replacement is sought.

Do not let those collapse into one sentence. A roof can be old and still suffer identifiable storm damage. Equally, a storm occurring nearby does not prove that every defect was caused by it.

Ask what evidence establishes the cause

A report should do more than describe age or condition. It should explain why the observed condition caused the particular damage. If the insurer says gradual deterioration was the cause, ask what observations, tests or photographs support that conclusion.

If you obtain your own evidence, ask the expert or tradesperson to address causation explicitly. A repair quotation alone may establish cost but not cause.

Storm disputes show why causation matters

The Financial Ombudsman considers the weather evidence, whether the damage is consistent with storm damage and whether the storm was the main cause. It does not treat a single universal wind-speed number as automatically deciding every claim.

It can also consider whether poor condition was the real cause or whether the storm caused damage despite some pre-existing wear.

If the insurer relies on an exclusion

Identify the exact exclusion and ask how the evidence satisfies it. The Financial Ombudsman’s published storm guidance states that where an insurer relies on an exclusion such as wear and tear or gradual damage, it will consider whether the insurer has shown that the exclusion applies.

What if more than one cause contributed?

Mixed-cause cases can be technically and legally difficult. Do not assume that identifying one excluded factor ends the analysis. Ask the insurer to explain how it treated the competing causes and whether the policy contains wording that addresses concurrent causes.

Where the value is substantial or the technical issue is complex, independent expert evidence or specialist legal advice may be proportionate.

Evidence that often matters

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