A complainant who sought cover after two porcelain crowns in his front teeth broke has lost a dispute after trying to claim under his home contents policy. 

The insured broke the crowns last September while he was having a meal. He lodged a claim with Insurance Manufacturers of Australia to have the crowns’ replacement paid for by the policy. 

The insurer declined the claim, saying it did not consider dental crowns as contents and that the circumstances of the loss were outside of the policy’s coverage. 

The claimant provided transcripts of an online chat with the insurer’s customer enquiry representatives that he says defined “General Contents” as “all contents inside your home that you own that is not permanently fixed to the building”.

He argues the crowns should fall under the policy’s definition as the items were “owned by him and not permanently attached to the home,” and “ordinarily kept in and around the house”, as he had typically been home for most of the day. 

The insured also says the event met the requirements for a valid loss as he had cover for accidental damage and the crowns “unexpectedly and accidentally broke while he was having a meal at home”. 

Insurance Manufacturers of Australia maintains the crowns were not covered as they could not be separated from the person, unlike other contents items such as clothing, jewellery or watches.

The insurer says the policy’s purpose is to “cover items specific to home and contents insurance, and not items affixed to a person” and that the crowns would fall under health insurance, which it does not provide. 

The Australian Financial Complaints Authority (AFCA) says it is “incorrect and inappropriate” for the complainant to read the policy’s definitions for terms such as “General Contents” in isolation and that the context of the policy should be considered when determining what items are covered. 

AFCA says the “commercial intent” of the policy is to cover items typically found or “kept in and around” the home on their own.

It says it is not fair to consider items physically and permanently attached to a person, such as the crowns, to be coverable under the intended definition of the policy. 

“While I accept the complainant’s dental crowns may have accidentally broken, I am not satisfied they are covered under his home contents policy on a fair and reasonable construction of its terms,” AFCA said.

“The crowns were only ‘in and around’ the home because they were permanently attached to a person that lives at the home.

“They are not items a person can ‘keep in and around’ their home on their own, detached from the person who resides at the home.”

The ruling acknowledges that the insurer’s customer enquiry representatives had told the complainant that the dental crowns would be considered “General Contents”. 

However, it says the customer enquiry representatives had likely not been informed that the insured’s claim had already been denied and did not have the appropriate information on the circumstances of the loss, in contrast to the claims department. 

“I consider it fair to rely on the insurer’s claims decision as setting out its formal position on the dental crowns,” AFCA said.

“As opposed to the customer enquiry representatives’ comments, this was an informed decision made after the insurer had fair and reasonable opportunity to consider the full context of the claim in line with the applicable terms.” 

Click here for the ruling.