AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
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.
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.
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.
Australia’s winter school holiday rush has put travel insurance back in the spotlight, with families heading to Bali, Fiji and Thailand, skiers travelling to New Zealand and domestic holidaymakers chasing either snow or sunshine closer to home. But this year’s peak period is unfolding against a more unsettled backdrop: geopolitical tension, airspace closures, airline disruption and a growing expectation that insurers should do more than reimburse costs after the event. - read more
The latest scrutiny of strata insurance arrangements is a timely reminder that insurance governance is no longer a back-office issue for property professionals. On 30 June 2026, the Insurance Brokers Code Compliance Committee released findings from a review of broker-agent arrangements in strata insurance. The review examined seven brokers with 1,088 strata representatives and identified weaknesses across representative agreements, remuneration disclosure, conflict management and oversight of conduct. - read more
Australia’s commercial insurance market may be softening on the surface, but the latest industry commentary suggests small businesses should be cautious about assuming every policy will automatically become cheaper. The emerging message is that the old idea of a single hard or soft insurance market is giving way to a more targeted pricing environment, where insurers assess each line of cover, occupation, location and claims history in much greater detail. - read more
Australian hospitality operators have another liability option to watch, after Haven Underwriting added broadform liability cover to its product line-up, backed by capacity from Mitsui Sumitomo Insurance. The product is aimed at several customer groups, including cafés, restaurants, wine bars and associated hospitality risks, with a stated limit of up to $20 million per policy. - read more
The ACCC’s fifth and final insurance monitoring report has given strata committees in cyclone-exposed regions a clearer view of what the Cyclone Reinsurance Pool is-and is not-achieving. Released on 25 June 2026, the report found that the pool has helped reduce or moderate premiums for policyholders in higher cyclone-risk areas, including residential strata schemes. - read more
Home insurance is an essential safeguard for homeowners in Australia, acting as a financial shield against unexpected damages and losses. It offers a sense of security, knowing that your largest asset is protected should the unforeseen occur. With the diverse range of natural perils that Australians face, from bushfires to floods, securing a home insurance policy is not just wise but almost indispensable. - read more
Financial planning is a crucial aspect of personal finance, enabling individuals to manage their money effectively and achieve their financial goals. For homeowners, financial planning takes on even greater significance. It involves not just handling your income and expenses, but also protecting valuable assets like your home and possessions. - 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
If you're running a business from your home, you may think that your homeowner's insurance policy has you covered. Unfortunately, this is not the case. Homeowner's insurance policies are not typically designed to cover business-related losses, leaving you vulnerable to significant financial risks if something goes wrong. - read more
For many Australians, their home is their castle, their sanctuary, and most significantly, their largest investment. Safeguarding this asset against unpredictable events is not merely a consideration—it's a necessity. That's where Total Replacement Cover comes into play. But what does this term really mean, and why is it paramount when it comes to choosing a home insurance policy? - read more
Knowledgebase
Loss of Use: Insurance coverage that pays for the additional living expenses if your home is uninhabitable due to a covered loss.
No comments yet. Be the first to share your thoughts.