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:
| Australian Food Super Implements Age-Based Insurance Premium Structure 03 Feb 2026: Paige Estritori Australian Food Super has announced a transition to age-based pricing for its insurance offerings, a move that will see premium costs vary according to members' age brackets. Effective November 1, 2025, this change aims to align insurance costs more closely with the risk profiles associated with different age groups. - read more |
| Australian Life and Income Protection Insurance Premiums Experience Notable Decline 03 Feb 2026: Paige Estritori Recent research from Rainmaker Information indicates a significant decrease in life and income protection insurance premiums across Australia. Direct life premiums have fallen by 7% since 2024, while direct income protection premiums have seen reductions of 12% and 13% for policies with 30-day and 90-day waiting periods, respectively. - read more |
| Global Insurtech Funding Sees Significant Decline Amid AI Surge 03 Feb 2026: Paige Estritori The global insurtech sector experienced a notable downturn in funding during the fourth quarter of 2024, with total investments halving to $US688.24 million compared to the previous quarter. This decline marks the lowest annual funding level since 2018, according to data from Gallagher Re. - read more |
| Australian Insurance Industry Set for Significant Growth Amid Rising Natural Disasters 03 Feb 2026: Paige Estritori The Australian general insurance industry is on a trajectory for substantial growth, with direct written premiums (DWP) projected to exceed $144 billion by 2029. This forecast, provided by data and analytics firm GlobalData, reflects a compound annual growth rate (CAGR) driven by increasing demand for coverage in response to the rising frequency of natural disasters. - read more |
| Understanding Your Insurance Needs at Every Life Stage Navigating the complex world of insurance can often feel daunting, but understanding the importance of life stage consideration when choosing life insurance is essential. As we journey through the various chapters of our lives, our financial responsibilities, dependents, and personal circumstances evolve. These changes invariably have significant implications for our insurance needs. - read more
|
| Creating a Financial Safety Net: Insurance and Savings Tips for Young Families Welcome to our blog! For young families, securing your future often requires careful planning and prudent financial decisions. One of the most crucial steps you can take in this journey is creating a financial safety net. - 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
|
| 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
|
A financial or other kind of interest in the insured item or person, necessary for a valid insurance contract.