Insurer Must Pay After Unfounded Fraud Allegations

1

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 claim was initially submitted in January 2022 for damage incurred to the man’s remote metal home in New South Wales. The insurer denied the claim on the grounds that the property was fraudulently misrepresented in terms of its status and functionality.

The policyholder, under heavy medication due to his illness, was questioned by the insurance company’s investigators. Unfortunately, he passed away roughly five months following the submission of the insurance claim. His estate's executor took over the complaint afterwards.

Recently, the Australian Financial Complaints Authority (AFCA) determined that the insurer, IAG, did not provide adequate evidence showing that the policyholder had breached his disclosure commitments. Thus, they must honour the claim.

According to AFCA, “Even if there had been a breach, the insurer has not convincingly shown that it resulted in the renewal of the policy when it would not have been otherwise. Thus, it is fair that the insurer accepts the claim.”

AFCA pointed out that IAG did not submit a declaration from its underwriters to either prove it would not have undertaken or renewed the policy. Despite cautions regarding potential adverse inferences, the insurer failed to provide necessary documentation on its underwriting practices pertaining to this case.

Originally, IAG contended that the policyholder had wrongly described the condition of his property upon policy initiation in October 2019, claiming it was watertight, structurally sound, secure, well-maintained, and inclusive of functional kitchen and bathroom facilities, and specifying its construction date as approximately 2019.

The policy contained a clause explicitly stating, “We don’t insure buildings under initial construction.”

AFCA’s investigation found that, as of the relevant policy renewal date in October 2021, the property's construction was completed, and it had been continuously occupied for over a year, meeting structural and maintenance codes.

“Each renewal constituted a new insurance contract,” the ombudsman declared.

Moreover, AFCA emphasized that the allegation of fraud, which carries grave implications, wasn’t sufficiently supported given that for a misrepresentation to amount to fraud, it must be made either knowingly or recklessly.

EVEN if I had determined that the policyholder breached the disclosure duty-which I have not-the insurer did not provide necessary proof to show it would not have entered the 2021-22 policy period without the alleged breach,” AFCA noted.

In their ruling, AFCA also highlighted the insurance contract and product disclosure statements omitted critical information regarding the duty to avoid misrepresentation, relevant disclosure duties, or consequences of any such breaches.

For more information on the ruling, it can be reviewed here.

This article has been adapted from one originally published by Insurance News Magazine.

Published:Wednesday, 3rd Jul 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

27 Oct 2025: Paige Estritori

Recent research conducted by the Insurance Council of Australia (ICA) and the Department of Foreign Affairs and Trade (DFAT) has revealed a concerning trend: one in seven Australian travellers embark on overseas trips 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

27 Oct 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

ASIC Initiates Legal Proceedings Against RACQ Insurance for Misleading Premium Information

19 Oct 2025: Paige Estritori

The Australian Securities and Investments Commission (ASIC) has commenced Federal Court proceedings against RACQ Insurance, a subsidiary of Insurance Australia Group (IAG), alleging that the insurer misled over 570,000 customers through deceptive premium comparison pricing in renewal notices issued between September 2019 and December 2024. - read more

Rising Travel Insurance Claims Among Australians Visiting Thailand

19 Oct 2025: Paige Estritori

Southern Cross Travel Insurance (SCTI) has reported a significant 43% increase in emergency assistance cases involving Australian travellers in Thailand compared to the previous year. This surge underscores the importance of comprehensive travel insurance for those venturing abroad. - read more

Open Insurance Unveils Innovative AI-Powered Travel Insurance for Australians

19 Oct 2025: Paige Estritori

Open Insurance, the parent company of the AI-driven brand Huddle, has launched a new travel insurance product tailored for the Australian market. This marks the company's return to offering travel insurance locally since the COVID-19 pandemic. - read more

Click for more Insurance News