AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

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.

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.

Published:Wednesday, 4th Sep 2024
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

BizCover and Zurich Collaborate to Enhance Professional Indemnity Insurance for Australian SMEs

05 Mar 2026: Paige Estritori

In a significant development for Australian small and medium-sized enterprises (SMEs), BizCover has announced the addition of Zurich's Professional Indemnity (PI) insurance product to its online platform, effective from 3 March 2026. This collaboration aims to provide SMEs with enhanced access to comprehensive PI coverage, addressing a critical need in the business community. - read more

Insurance Council of Australia Challenges Proposed Use of PI Insurance for Compensation Scheme

05 Mar 2026: Paige Estritori

The Insurance Council of Australia (ICA) has recently voiced strong opposition to proposals suggesting the use of professional indemnity (PI) insurance as a funding mechanism for the Compensation Scheme of Last Resort (CSLR). This stance was articulated in a submission to a Treasury consultation, where the ICA emphasized that PI insurance is not designed to serve as a consumer protection tool. - read more

ABC Insurance Faces Legal Setback in Professional Indemnity Insurance Dispute

05 Mar 2026: Paige Estritori

In a recent legal development, ABC Insurance has been ordered by the New South Wales Court of Appeal to pay the legal costs incurred by the Law Society of NSW in a dispute over professional indemnity insurance (PII) for solicitors. This ruling marks a significant setback for ABC Insurance in its efforts to challenge the existing PII framework for legal practitioners in the state. - read more

CHU Unveils Enhanced Residential Strata Insurance Policy

05 Mar 2026: Paige Estritori

CHU, Australia's leading strata insurance underwriting agency, has launched a new residential strata insurance policy designed to better support property owners and strata communities. This initiative reflects CHU's commitment to delivering customer-focused solutions that simplify insurance processes and enhance community resilience. - read more

ICA Advocates for Strata Law Reforms to Mitigate Rising Insurance Costs in Victoria

05 Mar 2026: Paige Estritori

The Insurance Council of Australia (ICA) has called for significant reforms to Victoria's strata legislation, highlighting that poor governance and deferred maintenance are leading to increased insurance premiums for the one in five Victorians residing in strata-titled properties. In a submission to the Expert Panel Review of the Owners Corporations Act 2006, the ICA emphasised that building defects are costing Australians an estimated $1. - read more

Click for more Insurance News