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.

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
Author: Paige Estritori

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.

Share this news item:

Insurance News

Clear

Mergers and Acquisitions Transform Australia's Insurance Landscape

03 Apr 2026: Paige Estritori

The Australian insurance industry is currently undergoing a significant transformation, marked by a surge in mergers and acquisitions (M&A). This trend is reshaping the market landscape, as companies seek to enhance their competitive edge and adapt to evolving regulatory and technological environments. - read more

MECON Enhances Construction Insurance Capacity to $120 Million

03 Apr 2026: Paige Estritori

In a significant development for Australia's construction sector, MECON has announced an increase in its underwriting capacity, now offering coverage up to $120 million for single projects. This enhancement, effective from March 10, 2026, applies to Section 1 (Material Damage) and includes Section 2 (Public Liability), providing more robust insurance solutions for larger and more complex construction endeavors. - read more

Escalating Costs Impact Construction Insurance Claims in Australia

03 Apr 2026: Paige Estritori

Australia's construction industry is currently facing significant challenges as rising costs reshape the insurance claims landscape. A recent report by Crawford & Company highlights that construction expenses are increasing at a rate faster than general consumer prices, with the Building Cost Index (BCI) rising nearly 5% annually. This trend is particularly evident in cities like Brisbane and Perth, where strong demand, logistical challenges, and a persistent shortage of skilled labour contribute to escalating costs. - read more

Australian Insurers Advocate for Stronger Consumer Protection Laws

02 Apr 2026: Paige Estritori

The Insurance Council of Australia (ICA) has expressed strong support for the proposed Competition and Consumer Amendment (Unfair Trading Practices) Bill 2026. This legislation seeks to introduce a general prohibition on unfair trading practices within Australian Consumer Law, thereby enhancing regulatory powers to address predatory operators in the insurance industry. - read more

APRA Takes Action Against Unjustified Commercial Auto Insurance Premium Increases

02 Apr 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has implemented emergency measures to address significant concerns within the commercial auto insurance sector. In response to widespread industry protests over substantial premium increases, APRA has introduced regulations aimed at safeguarding transport operators from financial hardship. - read more

Click for more Insurance News