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

NSW Productivity Commissioner Advocates for Immediate Ban on Strata Manager Commissions 22 Apr 2026: Paige Estritori In a significant development for New South Wales' housing sector, Productivity Commissioner Peter Achterstraat has called for the prompt elimination of commissions received by strata managers. This recommendation aims to bolster transparency and affordability within the state's burgeoning strata housing market. - read more

CHU's 2025 Strata Market Report: Stability in Strata Insurance Amid Rising House Insurance Costs 22 Apr 2026: Paige Estritori In its recently released 2025 State of the Strata Market report, CHU, Australia's leading strata insurance underwriting agency, provides an insightful analysis of the current landscape of strata insurance. The report underscores a notable stability in strata insurance premiums, which have seen a modest increase of 2.8% over the past year, rising from $954 to $981 per lot annually. This increment is significantly lower than the 14% surge observed in house insurance premiums during the same period. - read more

Insurance Council of Australia Advocates for Strata Law Reforms to Mitigate Rising Premiums in Victoria 22 Apr 2026: Paige Estritori The Insurance Council of Australia (ICA) has recently called for comprehensive reforms to Victoria's strata legislation, highlighting that inadequate governance and deferred maintenance are contributing to escalating insurance premiums for the state's strata property owners. This appeal underscores the pressing need for legislative updates to enhance the management and maintenance of strata-titled properties. - read more

Strengthening Small Business Resilience: ICA's Call for Insurance Reforms 22 Apr 2026: Paige Estritori In a recent submission to the Parliamentary Joint Committee's inquiry into small business insurance, the Insurance Council of Australia (ICA) has highlighted the pressing need for reforms to enhance the resilience of Australia's 2.5 million small businesses. These enterprises, which employ nearly half of the private sector workforce, are facing mounting challenges due to escalating insurance premiums and evolving risks. - read more