AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
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.
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.
Hutch Underwriting has unveiled Trade Pack, a comprehensive insurance solution designed specifically for Australia's small and medium-sized trade businesses (SMEs). This innovative product aims to streamline coverage and alleviate the administrative challenges often faced by brokers and tradies alike. - read more
Insurance Australia Group (IAG) has integrated generative artificial intelligence (AI) into its property claims assessment process, specifically to determine the necessity of 'make safe' repairs. This technological advancement aims to enhance operational efficiency and reduce costs associated with unnecessary contractor dispatches. - read more
Hollard Insurance has been ordered to pay over $225,000 in compensation after contractors appointed by the insurer caused significant dust damage during home repairs. This case underscores the critical importance of diligent contractor oversight in the insurance industry. - read more
Preventing injuries in the workplace is essential for ensuring the safety and well-being of employees. It also plays a critical role in maintaining a productive and efficient working environment. When workers are safe, they are more likely to remain healthy, motivated, and engaged with their tasks. - read more
Workers' compensation insurance is a form of insurance that provides financial protection for businesses and their employees in the event of workplace injuries or illnesses. It ensures that workers receive the necessary medical treatment and compensation for lost wages if they are hurt on the job. - read more
Insurance is a crucial aspect of business for tradespeople. Whether you are a sole trader or run a small trades business, having the right insurance coverage protects you from unexpected financial burdens. - read more
Dictionary
Double Indemnity
noun
A clause or provision in a life insurance policy that doubles the payout in cases of accidental death.
