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

Allianz Australia Penalised for Misleading Travel Insurance Information

15 Jan 2026: Paige Estritori

In a significant ruling, the Supreme Court of New South Wales has imposed fines totaling $16.8 million on Allianz Australia Insurance and its subsidiary, AWP Australia, for disseminating misleading information about their travel insurance products between 2016 and 2018. This decision underscores the critical importance of transparency and accuracy in the insurance sector. - read more

Surge in Medical Claims Among Australian Travellers Highlights Importance of Comprehensive Insurance

15 Jan 2026: Paige Estritori

In 2024, medical incidents emerged as the leading cause of travel insurance claims among Australian travellers, accounting for more than 40% of all claims handled by nib Travel. This trend underscores the critical importance of securing comprehensive travel insurance to mitigate the financial risks associated with medical emergencies abroad. - read more

Seafood Business Wins Insurance Dispute Over Storm-Induced Power Outage

15 Jan 2026: Paige Estritori

A recent ruling by the Australian Financial Complaints Authority (AFCA) has significant implications for businesses seeking insurance compensation for losses due to power outages caused by natural disasters. In this case, a seafood distribution company experienced substantial stock losses when a storm-induced power outage left its refrigeration systems inoperable for a week. The insurer initially denied the claim, citing a flood exclusion clause. - read more

Insurance Council Advocates for Liability Law Overhaul to Curb Rising Premiums

15 Jan 2026: Paige Estritori

The Insurance Council of Australia (ICA) has called for urgent reforms to civil liability laws to address the escalating costs of liability insurance premiums affecting businesses nationwide. In a recently released white paper, the ICA highlights the need to review state-based civil liability laws that have remained unchanged for nearly 25 years. The report identifies key areas requiring attention, including psychological injuries, worker-to-worker claims, and leisure and recreational risks. - read more

Australian Insurers See Profit Surge in Q3 2025

14 Jan 2026: Paige Estritori

In the third quarter of 2025, Australian general insurers reported a significant after-tax profit of nearly AUD 2.3 billion, marking an increase from approximately AUD 2.1 billion in the same period of 2024. This uptick reflects a combination of rising premium revenues and a reduction in claims, contributing to the industry's robust financial performance. - read more

Click for more Insurance News