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

Home Parking Dilemma Leads to Insurance Dispute Loss 09 Sep 2024: Paige Estritori A homeowner's struggle with her narrow driveway has culminated in the rejection of her car theft claim, illustrating the critical importance of adhering to insurance policy stipulations. - read more

Insurance Claim Rejected After Flight Crew Timing Violation 09 Sep 2024: Paige Estritori A traveler who faced a canceled flight due to the flight crew reaching their legal working hour limits will only receive partial reimbursement for his expenses. This ruling came from an official complaints authority. - read more

Allianz's Payout Reduction Approved in Car Claim Dispute 05 Sep 2024: Paige Estritori In a landmark decision, the Australian Financial Complaints Authority has ruled in favor of Allianz, allowing the insurer to significantly reduce its payout for a car damage claim due to a misdescribed vehicle model. - read more

Zurich Welcomes Fresh Leadership in Risk Management for ANZ Region 05 Sep 2024: Paige Estritori In a dynamic move, Zurich Financial Services Australia has named David Wainwright as the new Chief Risk Officer for the Australia and New Zealand region. This follows the retirement announcement of the current CRO, Jaimie Sach, a veteran with a distinguished 30-year career in the wealth management sector. - read more

AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case 04 Sep 2024: Paige Estritori A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end. - read more