AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.

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
Author: Paige Estritori

Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.

Share this news item:

Insurance News

Clear

Europ Assistance Australia Now Underwriting Its Own Travel Insurance Policies

07 May 2026: Paige Estritori

In a significant development for the Australian travel insurance sector, Europ Assistance Australia (EAA) has been granted a general insurance licence by the Australian Prudential Regulation Authority (APRA). This authorisation enables EAA to underwrite its own travel insurance products, marking a pivotal step in its commitment to the Australian market. - read more

ATIA Pushes for Permanent Travel Insurance Sales Rights for Agents

07 May 2026: Paige Estritori

The Australian Travel Industry Association (ATIA) is intensifying its efforts to secure a permanent authorisation for travel agents, tour operators, and accredited travel businesses to sell travel insurance at the time of booking. This initiative follows an exemption granted in 2021, which is set to expire in October 2026. - read more

Nib Divests World Nomads International Travel Insurance to Focus on Core Health Services

07 May 2026: Paige Estritori

In a strategic move to concentrate on its core health insurance operations, Nib Holdings has entered into a binding agreement to sell its World Nomads international travel insurance business to International Medical Group (IMG) for a cash consideration of $67.5 million. This transaction is subject to regulatory approvals and customary conditions, with the majority of proceeds expected within the current calendar year. - read more

Cover-More and Aon Forge New Travel Insurance Partnership in Australia

29 Apr 2026: Paige Estritori

In a significant development for the Australian travel insurance market, Cover-More, a subsidiary of Zurich's Cover-More Group, has entered into a strategic partnership with global brokerage firm Aon. This collaboration designates Cover-More as the exclusive provider of travel insurance products to Aon's Australian retail customers and employees. - read more

ATIA Intensifies Efforts to Secure Permanent Travel Insurance Sales Rights

29 Apr 2026: Paige Estritori

The Australian Travel Industry Association (ATIA) is actively campaigning to secure the permanent right for travel agents, tour operators, and accredited travel businesses to sell travel insurance at the time of booking. This initiative follows an exemption granted in 2021, which is set to expire in October 2026. - read more

Click for more Insurance News