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:
| Decline in Life and Income Protection Insurance Premiums Benefits Australians 24 Nov 2025: Paige Estritori Recent data indicates a notable decline in life and income protection insurance premiums across Australia, providing consumers with more affordable coverage options. According to the latest Direct Life Insurance Report from Rainmaker Information, direct life premiums have decreased by 7% since 2024. Similarly, direct income protection premiums have seen significant reductions, with average premiums for waiting periods of 30 days and 90 days decreasing by 12% and 13%, respectively. - read more |
| TAL's Health Sense Plus Now Covers Income Protection Policies 24 Nov 2025: Paige Estritori In a significant development for policyholders, TAL has expanded its Health Sense Plus program to encompass income protection (IP) policies. This initiative, effective from August 8, 2025, aims to incentivise proactive health management by offering premium discounts to clients who engage in preventative health checks. - read more |
| Marsh and Tokio Marine Kiln Introduce Port Disruption Insurance Amid Global Shipping Challenges 24 Nov 2025: Paige Estritori In response to escalating global shipping challenges, leading broker Marsh and Lloyd's underwriter Tokio Marine Kiln have launched a pioneering business interruption insurance specifically designed for ports. This innovative product aims to mitigate the financial impact of trade disruptions caused by various factors, including geopolitical tensions and operational strikes. - read more |
| Allianz Australia's Strategic Expansion: RAA Insurance Acquisition 24 Nov 2025: Paige Estritori In a significant move within the Australian insurance sector, Allianz Australia has successfully completed the acquisition of RAA Insurance for $642 million. This strategic acquisition, approved by the competition regulator on June 12, 2025, marks a substantial expansion of Allianz's footprint in the South Australian market. - read more |
| The Devil's in the Detail: What Your Income Protection Policy Really Covers In today's ever-fluctuating economic landscape, income protection insurance emerges as a vital component of comprehensive financial planning. While many understand the significance of insuring assets like homes and automobiles, securing one's income stream often gets overlooked. However, considering the life's unpredictable nature, safeguarding our ability to earn should be of utmost importance. - read more
|
| Income Insurance: Common Misunderstandings that Could Cost You When life throws unexpected challenges your way, income insurance can be a financial lifesaver. Essentially, it's a policy designed to replace a portion of your income if you're unable to work due to illness or injury. Imagine not having to worry about bills piling up while you focus on recovery. That's the peace of mind income insurance aims to provide. - read more
|
| The Role of Rehabilitation Benefits in Income Protection Insurance When the unexpected strikes, such as an illness or injury hindering our ability to earn a living, the financial repercussions can be devastating. This is where income protection insurance becomes a pivotal part of our financial safety net, ensuring a stream of income during challenging times. Income protection insurance is specifically designed to replace a significant portion of your salary if you're unable to work due to medical reasons, providing peace of mind and financial stability when you need it most. - read more
|
| How to Review and Update Your Life Insurance Policy as Your Family Grows Life insurance is an essential safety net for families, providing financial security when it's needed the most. As your family grows, the importance of having a well-structured life insurance policy becomes even more critical. In the busy lives we lead today, it’s easy to overlook this crucial aspect of financial planning. However, ensuring your coverage meets your family's evolving needs is vital. - read more
|
The amount you will have to contribute when you make a claim.