Insurance For Trades :: News
SHARE

Share this news item!

AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case?w=400
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.

Published:Wednesday, 4th Sep 2024
Source: Paige Estritori

Share this news item:

Insurance News

Broker Sentenced for Fraudulent Builders’ Insurance Scheme Broker Sentenced for Fraudulent Builders’ Insurance Scheme
15 Jan 2025: Paige Estritori

In a significant legal crackdown, a broker has been sentenced for his involvement in selling fraudulent builders’ warranty insurance to construction firms in New South Wales. This case underscores the urgent need for regulatory vigilance in the insurance sector. - read more
LA Wildfires Set to Shatter Insurance Loss Records LA Wildfires Set to Shatter Insurance Loss Records
14 Jan 2025: Paige Estritori

Recent wildfires in Los Angeles are projected to lead to unprecedented insured losses, potentially exceeding $20 billion USD (approximately $33 billion AUD). This alarming situation underscores the escalating risks associated with natural disasters, as communities brace for the fallout from this catastrophic event. - read more
Catastrophe Bonds: The Future of Cyber Risk Management Catastrophe Bonds: The Future of Cyber Risk Management
07 Jan 2025: Paige Estritori

As digital threats escalate, the financial sector is looking at innovative methods to enhance cyber risk management, with catastrophe bonds emerging as a pivotal tool. The Geneva Association emphasizes the necessity of alternative risk transfer solutions to mitigate the burgeoning cyber protection gap. - read more


Latest Financial Articles

How to Find the Best Travel Insurance Deals in Australia

15 Jan 2025 | Travelling is one of life's greatest joys, but it's not without its risks. This is where travel insurance comes into play for Australians. It ensures peace of mind, knowing that you're covered for unforeseen events such as medical emergencies, trip cancellations, or lost luggage.

How Much Life Insurance Does Your Family Actually Need?

14 Jan 2025 | Financial security for families is an essential consideration in any household. Life can be unpredictable, and ensuring that your loved ones are protected from financial hardship in your absence is a critical part of financial planning.

How Specialized Insurance Safeguards Australian Tradespeople

14 Jan 2025 | Specialized insurance for tradespeople is a form of tailored insurance coverage designed specifically to meet the unique needs and risks that professionals in various trades encounter. This includes trades such as electricians, plumbers, carpenters, and other similar occupations.