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

Fruit Fly Pressure Shows Biosecurity Is a Whole-Farm Insurance Issue

11 Aug 2026: Paige Estritori

Recent rural reporting on Queensland fruit fly pressure in horticultural regions is a timely reminder that biosecurity is not only a production issue. For orchardists, vegetable growers and mixed farms with small horticulture enterprises, a pest detection can affect far more than the crop in the paddock. It can influence picking schedules, packing arrangements, transport routes, labour planning, market access and cash flow. - read more

What Rising Insurance Complaints Mean for Truck Operators

06 Aug 2026: Paige Estritori

The latest insurance complaint trends are a timely warning for Australian truck owners, owner-drivers and fleet operators: the quality of a policy matters, but so does the way a claim is handled once something goes wrong. Across the general insurance sector, complaints continue to point to recurring pressure points such as delays, disputed decisions, communication gaps and confusion about policy terms. - read more

Why AI dash cameras are becoming an insurance issue for truck fleets

05 Aug 2026: Paige Estritori

The latest fleet technology coverage points to a clear shift in Australian transport: AI-enabled dash cameras, telematics and connected maintenance platforms are moving from optional extras to everyday risk-management tools. For truck operators, the insurance implications are becoming harder to ignore. - read more

NSW Workers Compensation Pressure Puts Tradie Employers on Notice

05 Aug 2026: Paige Estritori

Fresh attention on New South Wales workers compensation pricing is a timely reminder that insurance costs are not moving evenly across Australia. While some trade employers in other states have recently gained breathing room, NSW businesses are still operating in a market where scheme sustainability, claims duration and workplace injury trends remain under scrutiny. - read more

What Genetic Testing Reform Could Mean for Income Protection Applicants

05 Aug 2026: Paige Estritori

Australia’s move to restrict the use of adverse genetic test results in life insurance underwriting is an important development for people who have been hesitant to explore personal cover. While the reform is usually discussed in relation to life insurance, it also matters for income insurance because many retail policies sit within the broader life insurance framework. - read more

Click for more Insurance News