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
| 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 |
| Pelagic Risk Services Strengthens Commitment to Marinas with Gold Sponsorship 18 Dec 2025: Paige Estritori In a significant move to bolster support for the marina industry, Pelagic Risk Services has elevated its sponsorship status from Silver to Gold with the Marina Industries Association (MIA). This advancement underscores Pelagic's dedication to enhancing the operational capabilities and risk management strategies of marina operators across Australia. - read more |
| Australian Insurers Falling Behind in Cyber and AI Risk Readiness 18 Dec 2025: Paige Estritori In an era where digital threats are escalating, Australian insurers are reportedly less prepared to manage risks associated with cyber threats and artificial intelligence (AI) compared to their global counterparts. This insight emerges from the latest PwC Insurance Banana Skins Survey, which assesses the industry's readiness to tackle emerging challenges. - read more |
| Strategies to Use Life Insurance in Funding Shareholder Agreements Shareholder agreements lay the cornerstone for stable business relationships and continuity in Australia. Acting as a contract among business owners, these agreements set forth the expectations, rights, and obligations of all parties involved. They are particularly vital in delineating clear paths for dispute resolution, succession planning, and the transfer of ownership shares under varied circumstances, including the untimely death or departure of a shareholder. - read more
|
| The Savvy Traveller's Checklist for Affordable Travel Insurance Travel insurance is an indispensable component for any savvy traveller from Australia, playing a protective role in a myriad of situations that may occur away from home. Whether it's encountering flight delays, requiring medical assistance, or facing luggage theft, having a solid travel insurance policy can convert potential nightmares into manageable inconveniences. Yet, despite its importance, the process of finding a policy that won't break the bank is increasingly challenging. - read more
|
| The Single Parent’s Guide to Securing Your Child’s Financial Future Single parenting brings with it a mosaic of responsibilities and challenges, not least of which is securing a stable financial future for your child. The rollercoaster of raising a child alone often means that planning for the future can take a back seat to the day-to-day demands of parenting. Unexpected illnesses and injuries can compound these challenges, causing stress to multiply and plans to go awry. - read more
|
| How Life Insurance and Estate Planning Work Together for Your Benefit For many Australian families, the concept of estate planning might evoke imagery of vast wealth and complex legal documents, reserved for the very affluent. However, this misconception overshadows the universal importance of having an estate plan, which at its core, is about ensuring your loved ones are cared for and your wishes are honored upon your passing—even if you don't consider yourself wealthy. - read more
|