AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
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.
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.
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
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
Southern Cross Travel Insurance (SCTI) has reported a significant increase in domestic travel insurance claims, shedding light on the existing coverage gaps among Australian travellers. In the first eight and a half months of 2025, SCTI settled over $240,000 in claims related to local and interstate trips. - read more
Europ Assistance Australia (EAA) has achieved a significant milestone by obtaining a general insurance licence from the Australian Prudential Regulation Authority (APRA). This development allows EAA to underwrite its own travel insurance products, marking a new chapter in its commitment to Australian travellers. - read more
Recent insights from the Royal Automobile Club of Victoria (RACV) reveal a concerning trend among Australian travellers: 35% are purchasing travel insurance within seven days of departure, with 5% waiting until the day they leave. This last-minute approach can lead to significant gaps in coverage and benefits. - read more
Planning a trip is always an exciting experience, but it’s essential to be prepared for unexpected events. This is where travel insurance comes in. For Australian travelers, having the right travel insurance can make all the difference, offering peace of mind and financial protection. - read more
Picture this: You're all set for your dream vacation. Suitcases packed, tickets in hand, and the excitement building. But then, an unexpected disappointment hits. Your flight is cancelled. Suddenly, your well-laid plans are thrown into disarray. - read more
Travelling is an exciting adventure, but it comes with its own set of uncertainties. That's where travel insurance steps in, offering peace of mind by covering unforeseen expenses and emergencies. However, filing a travel insurance claim can sometimes be a daunting process. - read more
For many Australian travellers, setting off on a global adventure is an exciting prospect. Yet, amidst this excitement, it's crucial to acknowledge the unexpected twists and turns that could arise. That's where travel insurance steps in. Not just a safety net, it serves as a vital component of travel planning, providing peace of mind as you explore the world. - read more
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
Knowledgebase
Endorsement: An amendment or addition to an existing insurance policy that changes the terms or scope of the original policy.
