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

Understanding the 4.41% Increase in Health Insurance Premiums 18 Mar 2026: Paige Estritori Australian health insurance policyholders are set to experience a significant increase in their premiums, with an average rise of 4.41% scheduled to take effect from April 1, 2026. This adjustment marks the most substantial hike since 2017, when premiums rose by 4.84%. - read more

Rising Insurance Premiums in Australia: What Policyholders Need to Know 18 Mar 2026: Paige Estritori Recent industry reports indicate that Australian insurers are grappling with escalating claims costs and broader economic pressures, leading to adjustments in premium rates across various sectors. This trend is particularly significant for consultants and professionals who rely on comprehensive insurance coverage to mitigate risks associated with their services. - read more

Western Australia's Transport Sector Pushes for Enhanced Truck Licensing Standards 17 Mar 2026: Paige Estritori Western Australia's transport industry is urging the state government to implement more stringent heavy vehicle licensing requirements, aiming to bolster road safety and ensure drivers possess adequate experience. This initiative follows South Australia's recent reforms, which introduced tougher conditions for truck drivers after a tragic triple fatality in 2024. - read more

Aon's 2026 Report Highlights Escalating Climate Risks for Australian Businesses 17 Mar 2026: Paige Estritori Aon plc, a leading global professional services firm, has released its 2026 Climate and Catastrophe Insight report, shedding light on the escalating climate-related risks facing Australian businesses. The report indicates that insured catastrophe losses in Australia totaled an estimated US$2.9 billion in 2025, underscoring the growing financial impact of climate events on the insurance sector. - read more