AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

2

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
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

AFCA Criticises TAL for Unfair Termination of Income Protection Benefits

16 Nov 2025: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has recently ruled against TAL, a prominent life insurer, for terminating a policyholder's income protection benefits without prior notice. This decision underscores the critical importance of procedural fairness in the management of insurance claims. - read more

Actuaries Institute Highlights Financial Strain of Mental Illness on Insurance Systems

16 Nov 2025: Paige Estritori

The Actuaries Institute has issued a call for immediate action to address the escalating financial strain that mental illness is placing on Australia's insurance and compensation systems. This appeal underscores the pressing need to ensure the sustainability of the nation's financial safety net in the face of increasing mental health-related claims. - read more

Fitch Ratings Anticipates Continued Premium Increases in Australian Insurance Sector

16 Nov 2025: Paige Estritori

Fitch Ratings has projected that Australian insurers will continue to implement premium increases, with gross written premiums expected to grow by mid to high single digits. This forecast is driven by the need to offset rising claims and increased allowances for natural hazards. - read more

Surge in Cyber Insurance Adoption Among Australian Businesses

16 Nov 2025: Paige Estritori

In the past year, BizCover, a leading small business insurance provider, has reported an almost 50% rise in sales of cyber liability insurance. This significant uptick underscores the escalating awareness and concern among Australian businesses regarding cyber threats. - read more

IAG and Ag Guard Forge Partnership to Elevate Crop Insurance for Australian Farmers

14 Nov 2025: Paige Estritori

In a significant development for Australia's agricultural sector, Insurance Australia Group (IAG) has announced a strategic partnership with Ag Guard, a specialist rural underwriting agency. This collaboration will see Ag Guard managing the underwriting for IAG-owned CGU and WFI's crop insurance portfolios starting June next year. - read more

Click for more Insurance News