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:
| Significant Reduction in Farm Liability Claims Reflects Enhanced Safety Practices 25 Jan 2026: Paige Estritori Recent data from WFI Insurance indicates a substantial 75% decrease in farm liability claims over the past year, suggesting that Australian farmers are adopting more effective safety measures. This decline is particularly notable in incidents involving falls from height, which have reached their lowest level in four years. - read more |
| Heightened Road Risks During Holiday Season Due to Increased Freight Traffic 25 Jan 2026: Paige Estritori As Australia enters the summer holiday season, insurers and transport specialists are raising alarms about heightened road risks resulting from the convergence of increased freight activity and holiday travel. This period sees a significant uptick in both passenger vehicles and heavy trucks on the roads, amplifying the potential for accidents and safety incidents. - read more |
| Celebrating Excellence: 2025 National Trucking Industry Award Winners 25 Jan 2026: Paige Estritori The Australian Trucking Association (ATA) has proudly announced the recipients of the 2025 National Trucking Industry Awards, recognizing outstanding contributions and achievements within the sector. These awards highlight the dedication and excellence of individuals and organizations that drive the industry forward. - read more |
| Australian Insurers Achieve $6.1 Billion Profit in 2024 25 Jan 2026: Paige Estritori In 2024, Australia's insurance industry recorded an after-tax profit of $6.1 billion, a significant increase from the five-year average of $2 billion. This surge is primarily attributed to substantial premium hikes and a reduction in severe weather events. - read more |
| Life Insurance Audit: Regular Check-Ups for Your Policy's Health Life insurance serves as a crucial safety net, guarding your loved ones against the unforeseen. Just as you would take care of your health through regular check-ups, it is equally important to ensure that your life insurance policy remains in sound condition to provide the necessary protection. - read more
|
| Combining Financial Security and Affordability: Income Protection for Australians Explained Financial security is a cornerstone of peace of mind, particularly when life is known for its unpredictability. This introductory section sheds light on the vital nature of income protection insurance and its role in safeguarding Australians' financial well-being. Ensuring continual financial inflow during times of illness or injury not only offers stability but also protects one's standard of living. - read more
|
| Covering the Unexpected: A Guide to Trauma Insurance for Australian Families Trauma insurance, also known as critical illness insurance, is a type of coverage that provides a lump sum payment in the event that the insured suffers from a critical illness or injury. Unlike health insurance, which covers medical expenses, trauma insurance is designed to provide financial protection by helping to cover the additional costs associated with recovery from a severe illness or injury. - read more
|
| Making Sense of Income Protection Insurance: A Must-Read Comparison for Australians When life throws unexpected challenges our way, the assurance of financial stability can be a beacon of hope amidst the uncertainty. For many Australians, income protection insurance is that beacon, safeguarding their livelihood and providing a crucial safety net when they need it most. It's more than just a policy; it's a strategic step towards longer-term peace of mind. - read more
|
The periodic amount paid for the purchase of insurance.