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
Author: Paige Estritori

Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.

Share this news item:

Insurance News

Clear

Insuret and ATL Unite to Strengthen Australia's Truck Insurance Landscape

12 May 2026: Paige Estritori

In a significant development for Australia's transport insurance sector, specialist underwriting agencies Insuret and ATL have announced their merger, creating a unified national platform dedicated to fleet and trucking insurance. This strategic alliance is poised to address the evolving and complex risk demands within the country's transport and mobility sectors. - read more

Regulatory Scrutiny Intensifies Over IAG's Proposed Acquisition of RAC Insurance

12 May 2026: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has escalated its scrutiny of Insurance Australia Group's (IAG) proposed acquisition of Western Australia's RAC Insurance, initiating a second-phase review due to potential competition concerns. This development underscores the regulator's commitment to maintaining a competitive insurance market, particularly in regions where market concentration could adversely affect consumers. - read more

Australian Insurance Prices Decline as Global Conflicts Introduce Market Uncertainties

12 May 2026: Paige Estritori

Recent analyses by Aon indicate a notable decline in Australian insurance prices during the first quarter of 2026, with reductions ranging from 11% to 20% across various sectors. This trend is attributed to abundant market capacity and broader coverage options. However, escalating global conflicts, particularly in the Middle East, are casting shadows over the market's future stability. - read more

HESTA Announces Reduction in Insurance Fees to Benefit Members

11 May 2026: Paige Estritori

HESTA, a prominent Australian superannuation fund, has unveiled a significant reduction in insurance fees, set to take effect from 1 July 2026. This initiative aims to make insurance coverage more accessible and affordable for its members, aligning with the fund's commitment to enhancing member benefits. - read more

Hostplus and MetLife Australia Extend Partnership to Enhance Member Insurance Benefits

11 May 2026: Paige Estritori

Hostplus, a leading Australian superannuation fund, has announced the extension of its group insurance partnership with MetLife Australia until June 2028. This strategic move aims to elevate the servicing models across claims and underwriting, ultimately delivering stronger outcomes for Hostplus members. - read more

Click for more Insurance News