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.
Australian travellers who have long relied on credit card travel insurance now have a fresh reason to check their cover before leaving home, with several major banks reducing, restructuring or removing complimentary travel insurance benefits across selected cards. The changes do not mean every cardholder is uninsured, but they do mean past experience is a poor guide to what applies to the next trip. - read more
Safe Work Australia’s latest Key Work Health and Safety Statistics, released on 12 October 2026, provide a fresh reminder that construction remains one of the country’s highest-risk work environments. The national data records 41 construction worker fatalities in 2025 and shows construction accounted for 11.7% of serious workers’ compensation claims in 2024-25, making the figures directly relevant to trade businesses reviewing safety systems, contracts and insurance arrangements. - read more
A damaging hailstorm across Victoria’s Mallee has turned a promising harvest into a difficult insurance and cash-flow test for affected grain growers. ABC Rural reported on 6 November 2026 that hail swept through districts including Birchip, Wycheproof and Quambatook, damaging thousands of hectares of wheat, barley, lentils, canola and other crops just as many paddocks were ready to harvest. - read more
A recent Australian Financial Complaints Authority decision has highlighted a difficult but common issue for strata communities: damage that happens during a storm is not always insured storm damage. The dispute, reported on 5 November 2026, involved an owners corporation claim for a collapsed parapet wall, with the insurer declining cover on the basis that defective design, materials or workmanship were the dominant cause rather than the weather event itself. - read more
A new Australian healthcare professional liability market update points to a sharper divide between general insurance market conditions and the experience of healthcare organisations arranging malpractice and professional liability cover. Lockton’s 1 November 2026 update says established insurers remain selective, claims inflation is affecting attachment points and underwriters are looking more closely at how clinical governance works in practice, not merely whether accreditation exists. - read more
Comprehensive household coverage, often referred to as home insurance, is a policy designed to protect your home and its contents against a wide array of risks. This type of coverage typically includes protection against natural disasters, theft, vandalism, and various unforeseen events. In simple terms, it's the safety net that ensures peace of mind should the unexpected happen to your property or possessions. - read more
Home insurance serves as a critical safety net for homeowners, providing peace of mind and financial protection from unexpected events. In Australia, where Mother Nature’s whims can often result in extreme weather conditions, securing a robust home insurance policy isn't just wise—it's practically a necessity for safeguarding one of life's biggest investments. - read more
Natural hazard cover can vary significantly between Australian home and contents insurance policies. This guide explains how insurers commonly treat flood, storm, bushfire, cyclone, storm surge, actions of the sea and related events so you can read policy wording with more confidence. - read more
Home and contents insurance can provide valuable protection, but every policy has exclusions, limits and conditions. This guide explains common exclusions in Australian policies and what to check before buying, renewing or claiming. - read more
For many Australians, owning a home is a significant life achievement and a substantial financial investment. Protecting this asset is crucial, which is where home insurance becomes indispensable. As we navigate the complexities of life and confront the unpredictable forces of nature, the right home insurance acts as a financial shield against potential losses. Whether it's a natural disaster, accidental damage, or theft, having a robust insurance policy ensures that your home and peace of mind remain intact. - read more
Knowledgebase
Insurance Deductible: That part of an insurance claim that must be paid by an insured person before the the balance is paid by the insurer.
No comments yet. Be the first to share your thoughts.