Travel Insurance Online :: News
SHARE

Share this news item!

AFCA Upholds Fair Evaluation in Insurance Claim Dispute

AFCA Upholds Fair Evaluation in Insurance Claim Dispute

AFCA Upholds Fair Evaluation in Insurance Claim Dispute?w=400
The Australian Financial Complaints Authority (AFCA) has directed MetLife to re-evaluate a policyholder’s income protection claim, focusing on justified interpretations of mental health exclusions.

In a case brought to attention, the claimant, who secured his coverage via superannuation, applied for a $9300 monthly policy intended for a two-year coverage span back in March 2020.

The claimant's struggle began in August 2019 when his general practitioner declared him medically unfit for work due to "significant psychological distress," primarily catalyzed by workplace bullying.

As a recourse, the individual took personal leave in August followed by paternity leave in October of the same year. Although he resumed work in October 2020, he had to suspend his professional engagements again by December.

In September 2021, the claimant submitted a request for income protection benefits, citing an adjustment disorder diagnosed with mixed anxiety and depression as the reason inhibiting his capacity to work.

However, MetLife rejected the claim in July 2022, accusing the claimant of inaccurately representing his medical history. The insurance provider argued that the applicant falsely stated he hadn’t been “diagnosed with or sought medical advice or treatment” for psychological issues at the time of application.

MetLife asserted that the applicant already exhibited psychological distress, hindering his work capability long-term, and had they known, the policy would not have been issued. They determined his stress related symptoms equated “to a psychological condition.”

The claimant countered, maintaining he neither identified with a history of psychological ailments during his application process, nor would a typical person in his context.

AFCA elaborated, saying although the complainant experienced "significant stress in 2019," ordinary perception does not always align stress with a psychological or clinical mental health condition. The inquiry focused on awareness of any conditions at the time, not diagnosis existence.

AFCA highlighted that the treating GP did not insist on mental health assessments commonly expected when symptoms emerge, and the sole "treatment" employed was voluntarily steering clear of the work environment, a decision lacking a formal diagnosis.

They elucidated that “Even if the answers given were not actually true (because with the benefit of hindsight the complainant was in fact suffering from a psychological or mental health condition), the panel accepted a reasonable person in the circumstances would also have reached the same belief as the complainant did.”

Following the conclusion, AFCA mandates MetLife to process and revisit the claimant’s submission and communicate the outcome to Hostplus, the coverage trustee, within a 60-day frame. The original content was reported by the Australian Financial Review.

Published:Friday, 1st Nov 2024
Source: Paige Estritori

Share this news item:

Insurance News

Insurers Face Intense Scrutiny Over Quake Claim Rejections Insurers Face Intense Scrutiny Over Quake Claim Rejections
21 Nov 2024: Paige Estritori

In recent months, Muswellbrook, a town in New South Wales, has experienced a series of earthquakes that have left residents grappling with both physical destruction and emotional distress. Criticism is mounting against insurers as more than 600 claims have emerged, following these seismic events, yet many remain unresolved or denied. - read more
AI Regulations: A Web of Complications AI Regulations: A Web of Complications
20 Nov 2024: Paige Estritori

The Insurance Council of Australia (ICA) has raised concerns about the potential fallout from a fragmented regulatory approach to artificial intelligence and automated decision-making in the industry. There is fear that this patchwork of reforms could result in conflicting requirements, heavier compliance burdens, and increased industry confusion. - read more
APRA Survey Reveals Impact of Climate Change on Insurance Industry Practices APRA Survey Reveals Impact of Climate Change on Insurance Industry Practices
19 Nov 2024: Paige Estritori

A recent analysis by the Australian Prudential Regulation Authority (APRA) reveals that over 90% of general insurers and reinsurers anticipate climate change will influence their underwriting procedures, posing new challenges to the industry. - read more
Fraudulent Claims Lead to Complete Denial of Compensation Fraudulent Claims Lead to Complete Denial of Compensation
18 Nov 2024: Paige Estritori

In a remarkable case highlighting the severe consequences of insurance fraud, an individual's attempt to inflate a theft insurance claim has resulted in the total denial of compensation. Despite a significant portion of the claim being genuine, fraudulent actions negated any potential payout. - read more
Soaring Insurance Premiums Amid Changing Climate Soaring Insurance Premiums Amid Changing Climate
14 Nov 2024: Paige Estritori

As climate change persists, the impact of severe weather on insurance premiums is becoming more evident, pushing affordability out of reach for many Australians. Bernadette Systa, a mother of five, faced an undeniable financial strain as her annual home and contents insurance costs surged from a modest amount to more than twice what she initially paid. This experience echoes a growing dilemma faced by households across the country. - read more


Travel Insurance Articles

How to Save Money on Travel Insurance Without Compromising on Coverage How to Save Money on Travel Insurance Without Compromising on Coverage
Travel insurance is an essential component of any trip, providing protection and peace of mind for Australian travelers. Whether you are planning a short weekend getaway or an extended overseas adventure, unforeseen circumstances such as medical emergencies, trip cancellations, or lost luggage can quickly derail your plans and drain your finances. - read more
Cut Costs, Not Experiences: How to Plan a Budget-Friendly Australian Road Trip 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
Clever Ways to Save on Accommodation: Budget Travel Hacks for Aussies Clever Ways to Save on Accommodation: Budget Travel Hacks for Aussies
The concept of travel in Australia inherently brings to mind sweeping landscapes, rugged coastlines, and vast outback adventures. For many Australians, the dream of traversing this scenic wonderland is often tempered by the cold reality of expenses, with accommodation often being a prominent budgetary concern. Yet, far from dimming the wanderlust, this challenge invites a more clever approach to journeying through the land Down Under. - read more
Travel Troubles: How Travel Insurance Protects You from Unexpected Events Abroad Travel Troubles: How Travel Insurance Protects You from Unexpected Events Abroad
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
Traveling on a Budget: Money-Saving Tips for Australians Traveling Overseas 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
How to Save Money on Travel Insurance Without Compromising on Coverage How to Save Money on Travel Insurance Without Compromising on Coverage
Travel insurance is an essential component of any trip, providing protection and peace of mind for Australian travelers. Whether you are planning a short weekend getaway or an extended overseas adventure, unforeseen circumstances such as medical emergencies, trip cancellations, or lost luggage can quickly derail your plans and drain your finances. - read more
Travel Troubles: How Travel Insurance Protects You from Unexpected Events Abroad Travel Troubles: How Travel Insurance Protects You from Unexpected Events Abroad
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
The Essential Guide to Travel Insurance for Australians on a Working Holiday in Canada The Essential Guide to Travel Insurance for Australians on a Working Holiday in Canada
Welcome to your guide to embark on an amazing journey from Australia to the breathtaking landscapes of Canada on a working holiday. This adventure presents an inviting blend of work and travel, allowing you to immerse yourself fully in Canadian culture while supporting your explorations financially. - read more
Your Complete Guide to Understanding Travel Insurance Coverage 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
The Essential Guide to Travel Insurance for Australian Travelers The Essential Guide to Travel Insurance for Australian Travelers
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



Knowledgebase
Public Liability Insurance:
Insurance which provides protection against liability to third parties.