AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
2
The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.
However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.
In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.
The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.
While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.
"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.
"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."
The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.
"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.
For a more detailed account of the ruling, refer to the original report by AFCA.
The National Truck Accident Research Centre (NTARC) has released its 2025 Major Incident Investigation Report, shedding light on the primary human factors contributing to significant truck crashes across Australia. The findings emphasise the critical roles of inattention, distraction, and inappropriate speed in these incidents, underscoring the necessity for targeted safety interventions within the transport industry. - read more
QBE Australia Pacific has recently entered into a strategic partnership with Sure Insurance, aiming to bolster its broker-distributed householders cover. This collaboration signifies a concerted effort to provide more comprehensive and accessible home insurance solutions tailored to the diverse needs of Australian homeowners. - read more
Underwriting agency Blue Zebra has recently announced the establishment of new capacity arrangements for its home building and contents, landlord, and small to medium-sized enterprise (SME) package products. This strategic move is set to enhance the agency's ability to offer comprehensive and competitive insurance solutions tailored to the evolving needs of Australian homeowners and business operators. - read more
The Insurance Code Governance Committee has imposed a $30,000 penalty on AIG Australia for breaching its obligations related to claims handling. The insurer failed to inform customers about delays in processing their claims and neglected to advise them of their right to escalate complaints to the ombudsman. This regulatory action underscores the critical importance of transparency and communication in the insurance claims process. - read more
Insurance Australia Group (IAG), a leading insurer in Australia, has highlighted the significant impact of climate change on the cost of home insurance. The company reports that the increasing frequency and severity of weather events are contributing to rising premiums for homeowners. - read more
Experiencing damage or loss to your home can be a stressful and overwhelming experience. However, having home insurance provides a safety net for homeowners who need to file a claim. - read more
Household insurance is a type of coverage that protects you against financial losses from events such as theft, fire, or natural disasters. It typically includes two main components: building insurance, which covers the structure of the home, and contents insurance, which covers personal belongings within the home. - read more
Household insurance is a critical safety net for many Australian families. It protects against unexpected events such as natural disasters, theft, and accidents, ensuring that your home and belongings can be repaired or replaced if something goes awry. - read more
Home insurance serves as a critical safety net for homeowners, providing peace of mind and financial protection from unexpected events. In Australia, where Mother Nature’s whims can often result in extreme weather conditions, securing a robust home insurance policy isn't just wise—it's practically a necessity for safeguarding one of life's biggest investments. - read more
Understanding the significance of insurance in managing your finances is crucial. It acts as a safeguard, providing a buffer against unexpected losses or damage to your most valuable possessions. However, the costs associated with this necessary protection can be challenging to manage, especially when it comes to fitting insurance premiums into a monthly budget. - read more
Knowledgebase
Claim: A formal request made by the policyholder to the insurance company for payment of a loss covered by the insurance policy.
