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.
The Insurance Council of Australia (ICA) has recently submitted a series of recommendations to the Queensland Productivity Commission, aiming to address escalating insurance costs and bolster housing resilience across the state. These proposals are particularly pertinent to tradespeople, who are integral to the construction and maintenance of Queensland's housing infrastructure. - read more
In light of recent legislative changes, BizCover is urging registered building practitioners in New South Wales (NSW) to secure professional indemnity (PI) insurance well ahead of the July 1, 2026 compliance deadline. This advisory follows the extension of the enforcement date under the Design and Building Practitioners Act 2021, which now mandates that builders hold PI insurance deemed sufficient to cover potential liabilities. - read more
The Australian construction insurance market has experienced a notable shift in 2025, with premiums decreasing across various lines due to intensified competition among insurers. According to Marsh's Construction Insurance Market Update 2025, the first half of the year saw average premium reductions ranging from 5% to 15%, marking a significant departure from the upward trend observed in 2024. - read more
Public liability insurance is a type of coverage designed to protect you in the event that a member of the public is injured or their property is damaged because of your business activities. It's essential for tradespeople whose everyday work involves interacting with clients and the public—or working in environments where accidents could happen. - 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
As a tradesperson, having comprehensive insurance coverage is crucial. Whether you are a carpenter, electrician, plumber, or any other trades professional, the nature of your work exposes you to various risks. Insurance not only protects you but also your clients and your business. - read more
Dictionary
Occupational Hazard
noun
A risk associated with the nature of a particular occupation, which may affect insurance premiums.
