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.

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

QBE Insurance's Premium Growth Deceleration Impacts Share Value

29 Nov 2025: Paige Estritori

QBE Insurance Group, a prominent player in the Australian insurance sector, has recently experienced a notable decline in its share value, reaching a seven-month low. This downturn is primarily attributed to a slowdown in the company's premium rate growth during the third quarter of the 2025 fiscal year. - read more

ACCC Scrutinises IAG's Bid to Acquire RAC Insurance

29 Nov 2025: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has recently voiced concerns regarding Insurance Australia Group's (IAG) proposed acquisition of the Royal Automobile Club of Western Australia's (RAC) insurance business. Valued at A$1.35 billion, this deal aims to expand IAG's footprint in Western Australia. However, the ACCC warns that such consolidation could diminish competition in the state's motor and home insurance markets, potentially leading to higher premiums and reduced service quality for consumers. - read more

QBE Insurance Faces Market Challenges as Premium Growth Slows

29 Nov 2025: Paige Estritori

QBE Insurance Group, Australia's largest insurer by market value, has recently experienced a significant downturn in its share price, reaching a seven-month low. This decline is primarily attributed to a slowdown in the company's premium rate growth during the third quarter of fiscal 2025. For tradespeople across Australia, this development could have notable implications, particularly concerning insurance premiums and coverage options. - read more

ASIC Highlights Concerns Over Self-Managed Super Fund Advice

29 Nov 2025: Paige Estritori

The Australian Securities and Investments Commission (ASIC) has recently raised significant concerns regarding the quality of financial advice provided to individuals about self-managed superannuation funds (SMSFs). This development is particularly relevant for tradespeople considering SMSFs as a means to manage their retirement savings. - read more

Regulators Call for Action as Australia Faces Retiree Wave

29 Nov 2025: Paige Estritori

Australia's financial regulators, the Australian Prudential Regulation Authority (APRA) and the Australian Securities and Investments Commission (ASIC), have issued a strong warning to the country's A$4.5 trillion superannuation industry. They emphasize the urgent need to prepare for an anticipated influx of approximately 2.5 million retirees over the next decade. This development holds significant implications for tradespeople, many of whom rely on superannuation funds for their retirement savings. - read more

Click for more Insurance News