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:
| Heightened Road Risks During Holiday Season: Insurers Issue Warnings 19 Dec 2025: Paige Estritori As the Australian summer school holidays coincide with peak freight activity, insurers and transport specialists are raising concerns about heightened road risks. The surge in freight traffic, coupled with increased holiday travel, amplifies the potential for road incidents, particularly involving heavy vehicles. - read more |
| Rising Collision Risks Challenge Australian Fleet Operators 19 Dec 2025: Paige Estritori Australia's transport and haulage sector is currently navigating a period of heightened operational risk, marked by an uptick in both the frequency and severity of motor collision claims. This trend underscores the pressing need for fleet operators to adopt proactive risk management strategies and leverage advanced insurance solutions to safeguard their operations. - read more |
| Australian Life Insurance Premiums Set for 1.7% Growth in 2025 18 Dec 2025: Paige Estritori According to a recent report by Swiss Re, Australia's life insurance market is projected to experience a 1.7% real growth in premiums in 2025. This anticipated increase is attributed to easing cost-of-living pressures and the repricing of disability income policies. - read more |
| TAL's Health Sense Plus Now Covers Income Protection Policies 18 Dec 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 incentivize proactive health management by offering premium discounts to clients who engage in preventive health checks. - read more |
| Everything You Need to Know About Waiting Periods and Income Protection Benefits Income protection insurance is a crucial financial product designed to secure a portion of your income if you're unable to work due to illness or injury. This type of insurance acts as a financial safety net, ensuring that you can maintain your lifestyle and meet essential expenses while recovering. - read more
|
| Trauma Cover: Calculating Adequate Protection for Life's Unexpected Moments The financial fabric of our lives consists of both planning and safeguarding against the unforeseen. Trauma cover, a lesser-known but crucial aspect of personal insurance, provides this protection by offering a lump sum payment upon diagnosis of specific serious illnesses or injuries. In the tapestry of financial planning, it acts as a vital safety net, ensuring that unexpected health crises do not lead to monetary distress. - read more
|
| Tackling Unexpected Illness: How Income Insurance Can Help Maintain Your Standard of Living Illness limps in unannounced, derailing both physical health and financial stability without warning. When you're sideswiped by unexpected medical conditions, the uncertainty can compound, leading to a precarious balance of meeting health needs and financial commitments. Many are left pondering how to maintain their lifestyle amidst this turmoil. - read more
|
| Understanding the Role of Life Insurance in Your Estate Plan Estate planning is a critical process that often goes overlooked, but it's essential for securing the financial future of your loved ones and ensuring your assets are distributed according to your wishes. It involves the careful organization and protection of an individual’s estate to minimize uncertainties and facilitate the smooth transfer of assets after their passing. While it may seem complex, understanding the basics of estate planning is necessary for every Australian adult, regardless of wealth. - read more
|
The process by which an insurance company seeks to recover the amount paid to the policyholder from a third party responsible for the loss.