It Was Good Enough to Insure—Until It Was Time to Pay
When “wear and tear” becomes a post-loss substitute for causation analysis
CAUSED
IT?
There is something peculiar about the way “wear and tear” gets used in property insurance claims.
Before the loss, the property was acceptable to insure. The insurer had the right to inspect it, underwrote the risk, collected the premium, and issued the policy.
Then something happens. A storm comes through. A pipe fails. Wind hits the roof. The insured files a claim.
Suddenly, the age of the property becomes the entire explanation for why the insurer shouldn’t pay.
The roof is old. There’s deterioration. Maybe a “pre-existing condition.”
All of that might be true. But there’s a question that has to come before any of it matters: what actually caused the loss?
That’s a causation question. It doesn’t get answered by pointing at the calendar — and across the trade, it rarely gets asked at all.
A Trade-Wide Habit, Not a One-Off Tactic
This isn’t about one adjuster or one carrier. Denial-by-causation through “wear and tear” is standard practice across the entire insurance trade, and defense counsel leans on it just as readily as carrier adjusters do. The pattern repeats the same way every time: if the cause of loss isn’t immediately obvious from a quick look, the default conclusion becomes wear and tear. Not because an inspection proved it. Because it’s the easiest label available when nothing points to an obvious culprit, and because a denial written on that basis is cheap to produce and hard for a homeowner to fight without help.
The roof wasn’t 15 years old only when it got reported as damaged. The deterioration didn’t appear the moment the claim was filed. The insurer accepted the risk with the property in whatever condition it was already in, subject to the terms, conditions, exclusions, and limitations of the policy. That doesn’t mean an insurer has to pay for ordinary decay, or guarantees the condition of a roof forever. It means the mere existence of an aging, imperfect property doesn’t by itself explain what caused a later loss.
The roof is old, so age is the cause.
Age is a fact about the roof. It isn’t a finding about what happened to it. “This property has deterioration” and “deterioration caused this loss” are two different claims, and only one of them requires evidence anyone actually bothered to gather. A component can be old, deteriorated, even close to the end of its expected life, and still be functioning right up until an external event pushes it past the point of failure. “It was going to fail eventually” is not the same claim as “it failed independent of the reported event.” Eventually isn’t now.
This Isn’t a “Pay Every Claim” Argument
Not every damaged property has suffered a covered loss, and pretending otherwise would be exactly as lazy as the tactic being described here.
Materials deteriorate. Roofs reach the end of their service life. A pipe leaking slowly for months is a different claim than one that failed suddenly. A worn-out roof with no storm involved is a different claim than one damaged during a documented wind event. Those situations deserve to be judged on their own facts — the standard cuts the same way in both directions.
The Practical Tactic Hiding Behind “No Direct Opening”
Here’s where the rhetorical trick turns into a practical one, and it’s funny in the way that only genuinely frustrating things are funny.
Most policies require a “direct physical opening” caused by wind before wind-driven rain damage is covered. Carriers lean on that language constantly to deny water intrusion claims.
No missing shingle, no puncture, no direct opening — therefore no coverage.
Wind doesn’t need to punch a hole to get water under a roof. It lifts a shingle. It creases it. It breaks the seal along the tab line, with nothing torn off and nothing missing — nothing that shows up as damage in a photo taken from the ground three weeks later. The shingle still looks fine. And water gets in anyway. Not magically. Through the lifted edge and the broken seal, which is exactly the mechanism a roof’s wind resistance is supposed to prevent and, once defeated, exactly the mechanism that lets water through.
A lifted shingle is the opening. It’s just not the kind that photographs dramatically. The trade wants “opening” to mean “visible puncture” when that’s convenient, and nothing less than a puncture when a subtler mechanism is what actually happened. It can’t be both. If wind compromised the shingle enough to let water underneath it, wind created the opening the policy is talking about — whether that’s a two-inch tear or a hairline gap under a broken seal.
OPENING
That’s “wear and tear” wearing a different policy phrase. Both tactics do the same job: they let the carrier skip the one question a real investigation is supposed to answer — what mechanism actually let the water in — and substitute a label that doesn’t require proving anything.
Who Actually Made the Determination?
This deserves more scrutiny than it usually gets. Was the conclusion based on an inspection of the failed component itself? Was the mechanism of failure identified, or just assumed because the roof has some age on it? Is “wear and tear” doing the work an actual inspection was supposed to do?
There’s nothing wrong with concluding deterioration caused a loss, when that conclusion comes out of what was actually found on the property. The problem is when age becomes a substitute for the inspection instead of a finding that results from one.
The Standard Has to Cut Both Ways
Public adjusters have to support causation positions with evidence, not just assert a covered loss because a storm happened nearby. Carrier engineers have to do the same instead of defaulting to deterioration because it’s the cheaper conclusion to write. Contractors need to separate “this needs repair” from “this is what caused it.” Appraisers and umpires are resolving a factual dispute, not splitting a difference.
The standard shouldn’t shift depending on who’s paying for the report.
The Underwriting Question Nobody Wants to Ask
If a property was deteriorated enough that deterioration alone explains away a claim, how was that condition treated when the policy was written and the premium was collected?
This isn’t a claim that every defect has to be caught at underwriting, or that collecting a premium means every future loss is automatically covered — the policy still controls. But there’s a real difference between a property with ordinary age-related conditions and a property damaged by a later, reported event. If the first is being used to deny the second, the causal link needs to be demonstrated, not assumed because it’s convenient.
What Actually Happened
Almost every insured building has some wear and tear. That’s not remarkable on its own, and it doesn’t prove anything by itself.
The only question that matters is narrower: did the reported event cause the damage being claimed? Would it have happened the way it did, when it did, without that event?
If the honest answer is no, that should be provable — the mechanism, the prior condition, the absence of any real connection to the reported event. That’s a genuine causation finding, and it deserves to be treated like one.
“The roof is old” isn’t that finding. Neither is “there’s no hole,” when a lifted shingle does exactly what wind damage is supposed to do.
Insurance was never a promise that a building won’t age. It also isn’t supposed to come with a quiet asterisk that reads: unless we can find something old, or something that isn’t technically a hole, to point to instead.
Wear and tear may describe a condition. It doesn’t establish causation. Neither does the absence of a puncture wound in a roof that was never supposed to need one to let water through.
Would the damage have happened the way it did, when it did, without the reported event? That’s the only question that ever mattered.
Daniel “Jay” Jama · FL PA License W221110 · Homeowner Claims Help