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.

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.

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

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Allianz Australia Penalised for Misleading Travel Insurance Information

07 Jan 2026: Paige Estritori

In a significant ruling, the Supreme Court of New South Wales has imposed fines totaling $16.8 million on Allianz Australia Insurance and its subsidiary, AWP Australia, for disseminating misleading information about their travel insurance products between 2016 and 2018. This decision underscores the critical importance of transparency and accuracy in the insurance sector. - read more

Allianz Partners Highlights Risks of Travelling Uninsured

07 Jan 2026: Paige Estritori

Recent research conducted by the Insurance Council of Australia (ICA) and the Department of Foreign Affairs and Trade (DFAT) has unveiled a concerning trend: approximately 14% of Australian travellers embark on international journeys without any form of travel insurance. This statistic has prompted Allianz Partners to urge Australians to reconsider the importance of securing adequate coverage before travelling abroad. - read more

Surge in Medical Claims Among Australian Travellers Highlights Importance of Comprehensive Insurance

07 Jan 2026: Paige Estritori

In 2024, medical incidents emerged as the leading cause of travel insurance claims among Australian travellers, accounting for more than 40% of all claims handled by nib Travel. This trend underscores the critical importance of securing comprehensive travel insurance to mitigate the financial risks associated with medical emergencies abroad. - read more

Allianz Australia Penalised for Misleading Travel Insurance Information

30 Dec 2025: Paige Estritori

In a significant ruling, Allianz Australia Insurance and its subsidiary, AWP Australia, have been fined a total of $16.8 million for providing misleading information about their travel insurance products. The Supreme Court of New South Wales found that between 2016 and 2018, the companies misrepresented the extent of coverage available to consumers, leading to potential misunderstandings about policy benefits. - read more

Allianz Partners Highlights Risks of Travelling Uninsured

30 Dec 2025: Paige Estritori

Click for more Insurance News

Travel Insurance Articles

Traveling on a Budget: Money-Saving Tips for Australians Traveling Overseas

Traveling overseas is an exciting experience yet can be challenging, especially for Australians on a budget. With careful planning and budgeting, it is possible to make the most out of your trip without breaking the bank. This article provides valuable money-saving tips for Australians looking to explore the world on a restricted budget. - read more

Cut Costs, Not Experiences: How to Plan a Budget-Friendly Australian Road Trip

Australian landscapes are a canvas of breathtaking vistas, and road tripping offers an intimate brush with this vast, picturesque continent. The allure of the open road, the freedom to explore quirky roadside attractions, and the opportunity to discover secluded spots creates an excitement unique to this mode of travel. - read more

Top 5 Travel Insurance Features You Didn't Know Could Benefit You

Travel insurance is an essential consideration for Australians planning both domestic and international adventures. Whether you're jetting off to the beaches of Bali or exploring the bustling streets of Sydney, understanding the intricacies of travel insurance can protect you from unforeseen incidents that could derail your plans. - read more

Top Mistakes to Avoid When Buying Travel Insurance in Australia

Welcome to our guide on travel insurance! Whether you're planning a domestic getaway or an international adventure, travel insurance is a crucial part of your trip preparation. It provides peace of mind by covering unexpected expenses like medical emergencies, trip cancellations, and lost luggage. For Australian travellers, it is particularly important given the distance and expense often involved in overseas trips. - read more

Your Complete Guide to Understanding Travel Insurance Coverage

Imagine you're on a dream holiday in Europe and suddenly fall ill. Without travel insurance, this unforeseen mishap could turn your trip into a financial nightmare. Unexpected travel mishaps can occur, from medical emergencies to lost luggage, and having travel insurance can provide a safety net. - read more

Knowledgebase

Moral Hazard:
The concept that individuals may take on more risk when they do not bear the full consequences of that risk, often relevant in insurance scenarios.

This website is owned and operated by Clark Family Pty Ltd (ACN 010 281 008) as Trustee for the Clark Family Trust (ABN 35 957 893 714), 43 Larch Street Tallebudgera QLD 4228. Clark Family Pty Ltd is an Authorised Representative (AR 1298860) of Unique Group Broker Services Pty Ltd (AFSL 509434) for financial product referrals and an Authorised Credit Representative (ACR 401491) of Saccasan Pty Ltd (ACL 386297). Check our licensing details on the ASIC registers: Clark Family Pty Ltd ACR, Clark Family Pty Ltd AR, Saccasan Pty Ltd, Unique Group Broker Services.

IMPORTANT: We do not provide financial product advice or credit assistance. We act solely as an introducer and refer enquiries to licensed third-party intermediaries, insurers, and lenders - with whom you can then deal directly. We may receive a fee or commission from these third parties in consideration for the referral. Before any action is taken to obtain a product or service referred to by this website, advice should be obtained (from either the third party to whom we refer you or from another qualified intermediary) as to the appropriateness of obtaining those products having regard to your objectives, financial situation and needs. Whilst we have our own process for validating the legitimacy of our referral partners, you should always verify the credentials of your financial adviser before proceeding with recommendations that they may present. Visit the ASIC website for further information.