Insurer Must Pay After Unfounded Fraud Allegations
Insurer Must Pay After Unfounded Fraud Allegations
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 leading insurance company has been ordered to cover a fire damage claim submitted by a policyholder who passed away from cancer two years ago, highlighting the consequences of unjust fraud accusations.
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.
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.
A recent travel insurance dispute reported by Insurance News has put a spotlight on one of the most important parts of any cancellation claim: timing. The case involved a policyholder who argued that a doctor’s declaration that he could not travel overseas was the relevant claimable event, rather than the earlier appearance of illness. The policyholder was successful, reinforcing that the way a medical issue is documented can be just as important as the condition itself. - 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
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 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 (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
Travelling is one of life's greatest joys, but it's not without its risks. This is where travel insurance comes into play for Australians. It ensures peace of mind, knowing that you're covered for unforeseen events such as medical emergencies, trip cancellations, or lost luggage. - read more
When it comes to travelling abroad, there's more to preparation than just packing the right clothes and booking your flights. For Australian travellers venturing overseas, assembling a financial travel kit is just as vital as a passport. This kit serves as your safeguard, ensuring that even when faced with the unpredictable, your journey remains as smooth as possible. - read more
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 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 insurance is a crucial aspect of planning a trip, especially for Australian travelers who venture far and wide. With the vast array of destinations Australians frequent, from exploring the natural wonders of the Outback to adventuring abroad, having a safety net in place can provide peace of mind. - read more
Knowledgebase
Incontestability Clause: A provision in a life insurance policy that prevents the insurer from voiding coverage due to a misstatement by the insured after a certain period.
No comments yet. Be the first to share your thoughts.