AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

2

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
Source: Paige Estritori

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

Share this news item:

Insurance News

Clear

Allianz Partners Highlights the Risks of Travelling Uninsured

14 Dec 2025: Paige Estritori

Recent research commissioned by the Insurance Council of Australia (ICA) and the Department of Foreign Affairs and Trade's (DFAT) Smartraveller program 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

14 Dec 2025: 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

Rising Travel Insurance Claims Among Australians Visiting Bali

14 Dec 2025: Paige Estritori

The allure of Bali continues to captivate Australian travellers, with a notable 43% increase in travel insurance policies purchased for the destination since the 2022/23 summer season. This surge has corresponded with a 50% rise in related insurance claims, now accounting for 16% of all claims submitted to Southern Cross Travel Insurance (SCTI) in 2024. - read more

Unveiling Hidden Exclusions in Travel Insurance Policies

12 Nov 2025: Paige Estritori

Australian travellers are being urged to carefully review their travel insurance policies to identify potential exclusions that could affect their coverage. Legal expert Peter Carter from Carter Capner Law highlights that certain activities, such as riding motorbikes or jet skis and consuming alcohol, are often classified as high-risk by insurers. Incidents occurring during these activities may lead to claim rejections. - read more

Qantas Travel Insurance Honoured with Mozo Experts Choice Award 2024

04 Nov 2025: Paige Estritori

Qantas Travel Insurance has been recognised in the 2024 Mozo Experts Choice Awards for Travel Insurance, showcasing its exceptional value for their Annual Multi Trip Travel Insurance policy. - read more

Click for more Insurance News