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 construction sector remains under pressure, with recent insolvency figures continuing to show building and construction as one of the most exposed parts of the economy. Higher material costs, tight margins, labour shortages, delayed payments and fixed-price contract stress have all contributed to a tougher operating environment for builders, subcontractors and project owners. - read more
Recent transport industry sales updates point to a more selective new-truck market, with operators weighing replacement timing against finance costs, emissions planning, availability and contract confidence. For truck businesses, that matters well beyond the showroom. A change in buying momentum can flow through to vehicle values, repair economics, insurer appetite and the way fleets should set insurance sums before renewal. - read more
Fresh small business cyber warnings are a practical reminder that digital risk is no longer just a concern for large companies with complex IT systems. For Australian tradespeople, the most damaging cyber incident may be far simpler: a fake invoice, altered bank details, a compromised email account or a scam message that looks like it came from a supplier, builder, real estate agent or client. - read more
ASIC’s continuing focus on superannuation member services has put another practical issue in front of Australian workers: insurance inside super is not just about whether cover exists, but whether members can understand and use it when they need help. Recent regulatory attention on trustee administration, communication and claims support is a timely reminder for anyone relying on salary continuance or income protection benefits through their fund. - read more
Recent transport industry reporting has again highlighted growing interest in Performance Based Standards vehicles and other high-productivity truck combinations across Australia. For operators, the attraction is clear: fewer trips, better payload efficiency and stronger productivity on approved routes. For insurers, however, the shift is not simply a matter of adding another truck to the schedule. PBS combinations can alter exposure across vehicle value, route compliance, load responsibility, driver capability and recovery after an incident. - 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
Renovating can improve your home's value, comfort and liveability, but it can also change the risks your insurer is covering. Before work starts, it is important to review your home and contents insurance, check exclusions and limits, and understand whether extra cover or policy changes may be needed during the project. - read more
Household insurance, commonly referred to as home insurance, is a type of policy that provides financial protection for your home and belongings against damage, theft, or loss. In Australia, this type of insurance is crucial for homeowners and renters alike, offering peace of mind in the face of unexpected events. It's designed to help you recover and rebuild without bearing the full financial burden yourself. - read more
In the face of unpredictable climate patterns and wild weather, safeguarding your home becomes a top priority, especially in a country like Australia. Choosing the right home and contents insurance is essential in providing a financial safety net against the forces of nature. With this in mind, the importance of insurance cannot be overstated, acting as a crucial buffer to protect your property and belongings. - read more
It’s easy to think of household insurance as something you purchase once and forget about. However, this approach can leave you vulnerable to unexpected risks. Your home and its contents change over time, and so do your insurance needs. - read more
Knowledgebase
Grace Period: A time period after the premium is due during which an insurance policy remains in force even if the premium has not yet been paid.
No comments yet. Be the first to share your thoughts.