AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

2

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

Clear

Half a Million Australian Homes at Risk of Becoming Uninsurable, Climate Agency Reports 21 Jun 2025: Paige Estritori The Climate Change Authority has released a concerning report highlighting that, without immediate intervention, extreme natural hazards could cost Australians approximately $8.7 billion annually by 2050. The report urges the federal government to spearhead a comprehensive and well-coordinated national adaptation agenda to mitigate these risks. - read more

Red Sea Unrest: Insurer Denies Cruise Cancellation Claim 20 Jun 2025: Paige Estritori An Australian travel policyholder has been denied a claim payout after his planned cruise in the Red Sea was cancelled due to conflict. The insurer, Southern Cross, invoked its policy's war and violence exclusion clause, as disturbances in the region were linked to military activities, rendering the claim invalid. - read more

Recognition at ACT Insurance Awards Highlights Industry Leaders 18 Jun 2025: Paige Estritori The ACT Insurance Awards have recently acknowledged the standout performers within the insurance sector, with EML Group's Canberra branch receiving the prestigious title of Insurance Leader of the Year. This accolade sets a benchmark in the industry, emphasising excellence and leadership among its professionals. - read more

TAL Collaborates with Insurtech to Launch Embedded Life Insurance 17 Jun 2025: Paige Estritori Australia's prominent life insurer, TAL, has partnered with the global insurtech firm, Cover Genius, to introduce an innovative 'digital-only', embedded life insurance product. This new solution aims to serve Australian workers such as part-time employees, contractors, and casual staff who often lack access to affordable insurance coverage. - read more

Growing Mistrust in New Zealand Insurers Amid Rising Costs 17 Jun 2025: Paige Estritori Recent findings from a Consumer NZ survey highlight increasing skepticism towards insurers in New Zealand, as affordability remains a significant concern for many. The survey noted that insurance now ranks as the fourth-largest financial pressure among respondents, trailing housing, food, and household debt, marking an upward shift from sixth place last October. This change has negatively impacted the industry's reputation, with more individuals expressing distrust towards insurers. - read more