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:

Insurance News

APRA's Intervention: Freezing Unjustified Premium Hikes in Commercial Auto Insurance 06 Apr 2026: Paige Estritori The Australian Prudential Regulation Authority (APRA) has recently taken decisive action to address escalating concerns within the commercial auto insurance sector. In response to widespread industry protests over substantial premium increases, APRA has implemented emergency regulations aimed at protecting independent transport operators and logistics enterprises from potential financial distress. - read more

Navigating 2026: Key Challenges Identified by Australian Insurers 06 Apr 2026: Paige Estritori As 2026 unfolds, Australian insurers are confronting a trio of pressing challenges that are reshaping the industry's landscape. According to insights from Gallagher Bassett's upcoming report, 'The Carrier Perspective: 2026 Claims Insights,' the foremost concerns include rising premium costs coupled with shrinking insurability, escalating cyber and data risks, and increasing difficulties in attracting and retaining skilled workers. - read more

Addressing the Looming Truck Driver Shortage in Australia 06 Apr 2026: Paige Estritori Australia's transport industry is sounding the alarm over a significant and growing shortage of truck drivers, a situation that poses a substantial threat to the nation's supply chain. The National Road Transport Association (NatRoad) has highlighted that the current shortfall of approximately 28,000 drivers is projected to escalate to 78,000 unfilled positions by 2029, representing a 26% decrease from the current workforce of 189,900 drivers. - read more

APRA Emphasises Immediate Action on Extreme Weather Mitigation 06 Apr 2026: Paige Estritori The Australian Prudential Regulation Authority (APRA) has released a pivotal report highlighting the pressing need for immediate and substantial action to shield communities from the escalating impacts of extreme weather events. This Insurance Climate Vulnerability Assessment (ICVA) serves as a stress test, modelling potential future scenarios rather than forecasting specific outcomes. However, the risks outlined are already becoming evident, reinforcing the insurance industry's calls for urgent intervention to mitigate extreme weather risks. - read more