AFCA Upholds Fair Evaluation in Insurance Claim Dispute
AFCA Upholds Fair Evaluation in Insurance Claim Dispute
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 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.
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.
Partners Life has introduced a new Life Advantage discount, giving eligible customers a permanent reduction on selected life and trauma-related covers. The offer is aimed at non-smokers aged 16 and over who meet a specified body mass index range and complete full medical underwriting when applying for new or increased cover. - read more
A new regulatory focus on insurer operational resilience is a timely reminder that an income insurance policy is only as reassuring as the systems behind it. The Financial Markets Authority review, reported by Insurance Business in July 2026, found that many New Zealand insurers are still relying on ageing technology for core operations, while also managing significant outsourcing and cyber-security pressures. - read more
New Zealand’s life and health insurance market is facing a quiet but important shift: younger adults are not necessarily rejecting protection, but many are postponing the life events that usually trigger it. Recent industry reporting, drawing on Deloitte and Financial Services Council research, shows Gen Z and millennial New Zealanders are delaying major decisions such as buying a home, starting a family, changing careers or launching a business because of financial pressure. - read more
New Zealand’s younger workers are reshaping the traditional path into insurance. Fresh industry reporting, drawing on Deloitte’s 2026 Gen Z and Millennial Survey and Financial Services Council research, points to a clear shift: many Gen Z and millennial New Zealanders are delaying major life decisions because of financial pressure. Home ownership, starting a family and career changes have long been moments when people reassess life, mortgage and income protection cover. - read more
New Zealand’s financial advice sector is heading into a more targeted year of scrutiny after the Financial Markets Authority’s latest conduct priorities highlighted fraud, adviser commissions and complaints handling as areas of concern for 2026/27. For households arranging life, trauma, income protection or health-related cover, the message is practical: the quality of advice, disclosure and record keeping matters just as much as the premium on the page. - read more
Estate planning is a process that involves the management and distribution of an individual's assets and responsibilities in the event of their passing or incapacitation. It is an essential part of financial planning that ensures your assets are managed according to your desires and your loved ones are taken care of. - read more
Life is an unpredictable journey filled with twists and turns that can challenge even the most prepared among us. Sudden illnesses and unexpected injuries are just some of the uncertainties that can disrupt the harmony of family life. The emotional turmoil brought on by these circumstances is often compounded by the financial strain they can cause. It's during these trying times that the true value of peace of mind becomes clear. - read more
Life insurance remains one of the most crucial considerations for new parents aspiring to provide a secure future for their growing families. The arrival of a child marks a transformative moment, redefining priorities and responsibilities. At its core, life insurance is a safety net, designed to offer financial protection and stability to loved ones in the event of an unforeseen tragedy. - read more
Life insurance is a critical component of a sound financial plan. It provides financial security and peace of mind to you and your loved ones, ensuring that they are taken care of in the event of your untimely death. - read more
Life insurance is an essential financial protection that provides peace of mind to policyholders and their loved ones. The premiums you pay are determined by various factors, including age, health, lifestyle, and occupation. - read more
Knowledgebase
Public Liability Insurance: Insurance which provides protection against liability to third parties.
No comments yet. Be the first to share your thoughts.