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.

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
Author: Paige Estritori

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.

Share this news item:

Insurance News

Clear

SCTI Highlights Increase in Domestic Travel Insurance Claims and Coverage Gaps

14 Jun 2026: Paige Estritori

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

Allianz Partners Strengthens Australian Presence with nib Acquisition

07 Jun 2026: Paige Estritori

In a significant development within the Australian travel insurance industry, Allianz Partners has announced the acquisition of a substantial portion of nib Group's travel insurance portfolio in Australia and New Zealand. This strategic move, valued at up to A$50 million, marks a pivotal expansion for Allianz Partners in the Asia-Pacific region. - read more

Freely Launches Tailored Travel Insurance Plans for Australians

07 Jun 2026: Paige Estritori

Freely Travel Insurance has unveiled three innovative travel insurance plans designed to cater to the varied needs of Australian travellers. The newly introduced plans-Essentials, Explorer, and Explorer Pro-offer different levels of coverage, ensuring that individuals can select a policy that aligns with their specific travel requirements and budgets. - read more

Europ Assistance Australia Gains APRA Approval to Underwrite Travel Insurance

07 Jun 2026: Paige Estritori

Europ Assistance Australia (EAA) has achieved a significant milestone by obtaining a general insurance licence from the Australian Prudential Regulation Authority (APRA). This authorisation enables EAA to underwrite its own travel insurance products, marking a pivotal step in its commitment to the Australian market. - read more

Europ Assistance Australia Begins Underwriting Its Own Travel Insurance Policies

31 May 2026: Paige Estritori

In a significant development for the Australian travel insurance sector, Europ Assistance Australia (EAA) has been granted a general insurance licence by the Australian Prudential Regulation Authority (APRA). This authorisation enables EAA to underwrite its own travel insurance products, marking a pivotal step in its commitment to the Australian market. - read more

Click for more Insurance News