AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
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:
| Learning from Near Misses: Enhancing Farm Safety in Australia 18 Feb 2026: Paige Estritori In July 2025, Farmsafe Australia launched the 'Second Chances – Who Knows How Many You'll Get' campaign, aiming to transform near misses on farms into learning opportunities to prevent future accidents. This initiative underscores the critical importance of recognising and addressing close calls in agricultural settings. - read more |
| WFI's 2025 Farm Accident Insights: A Call for Enhanced Safety Measures 18 Feb 2026: Paige Estritori In October 2025, WFI Insurance unveiled its annual farm accident insights as part of Farmsafe Australia's 2025 Safer Farms Report. The findings paint a stark picture of the challenges facing Australian agriculture, with 2024 recording 72 farm-related deaths—the highest in over two decades. - read more |
| ASIC Highlights Deficiencies in Insurers' Complaint Handling Practices 18 Feb 2026: Paige Estritori The Australian Securities and Investments Commission (ASIC) has recently conducted a comprehensive review of insurers' complaint handling processes, uncovering significant deficiencies that fail to meet regulatory obligations. The findings indicate that insurers are not adequately identifying and addressing customer complaints, with one in six complaints going unrecognized. Additionally, systemic issues are often overlooked, communication timeframes are missed, and existing systems fail to record outcomes such as compensation payments. - read more |
| Forecast: Continued Decline in Australian Commercial Insurance Rates Through 2026 18 Feb 2026: Paige Estritori Following a significant 12% decline in commercial insurance rates during the fourth quarter of 2025, industry experts anticipate that this downward trend will persist throughout 2026. The Australia-Pacific region has been at the forefront of this global decrease, with the recent drop marking the steepest since early 2024. - read more |
| How to Protect Your Income During Health Setbacks: A Complete Guide Income protection is a crucial safety net for Australians, offering financial security when health setbacks strike. This type of insurance ensures that you continue to receive a portion of your income if illness or injury prevents you from working. It’s an essential aspect of financial planning, providing peace of mind knowing that you can maintain your lifestyle even when unforeseen health issues arise. - read more
|
| Income Protection Insurance Explained: Ensure Your Livelihood in Times of Uncertainty When life takes an unexpected turn, whether due to illness, injury, or other unforeseen events, the financial repercussions can be devastating. This is where income protection insurance becomes an essential component of maintaining financial stability. Income protection insurance acts as a safety net, ensuring that even in times of hardship, your financial obligations can be met, and your standard of living maintained. It provides peace of mind, knowing that your earnings are safeguarded should you become unable to work due to health reasons. - read more
|
| How Life Insurance and Estate Planning Work Together for Your Benefit For many Australian families, the concept of estate planning might evoke imagery of vast wealth and complex legal documents, reserved for the very affluent. However, this misconception overshadows the universal importance of having an estate plan, which at its core, is about ensuring your loved ones are cared for and your wishes are honored upon your passing—even if you don't consider yourself wealthy. - read more
|
| Life Insurance and Estate Planning: What You Need to Know Life insurance and estate planning are critical components of financial security. They ensure that your loved ones are protected financially when you are no longer around. By understanding these tools, you can take significant steps to secure your family's future. - read more
|
The periodic amount paid for the purchase of insurance.