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.â€
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.â€
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.
The latest phase of New South Wales strata reform has brought strata insurance disclosure back into practical focus, moving the issue from policy debate to renewal-season reality for owners corporations. The changes are designed to make it clearer when a strata managing agent, broker, insurer or related party receives a commission, fee or other financial benefit connected with arranging insurance. - read more
Fresh life insurance performance data from APRA points to a market that is steadier than the disrupted conditions seen in recent years, but not one where employers can afford to be passive. For CFOs, HR leaders and directors, the message is less about a single quarterly result and more about the operating environment behind corporate life insurance pricing, claims service and product design. - read more
A fresh push to reform how NSW funds emergency services has put insurance affordability back in the spotlight, especially for small businesses that already feel every increase at renewal time. The issue centres on the Emergency Services Levy, which is applied through many insurance policies and has long been criticised by parts of the insurance sector as a disincentive to maintaining adequate cover. - read more
Australia’s tougher operational risk regime is sharpening the focus on how life insurers manage the systems, partners and processes that sit behind every policy. APRA’s CPS 230 standard requires regulated insurers to identify critical operations, set clear disruption tolerances and strengthen oversight of material service providers. For customers, this is not just a back-office compliance story. - read more
Fresh compliance attention on life insurance claims handling is a timely reminder that cover is only valuable if it can respond clearly and efficiently when a business is under pressure. Recent industry monitoring has again highlighted familiar issues for life insurers, including claim delays, communication gaps, repeated evidence requests and the need for more consistent support where customers are vulnerable or dealing with complex medical events. - read more
Life insurance premiums in Australia are shaped by a mix of personal, health, lifestyle and policy choices. This guide explains the main cost factors, how underwriting works, and why quotes can vary between insurers. - read more
The importance of life insurance in financial planning: Life insurance isn’t just a policy; it’s a cornerstone of comprehensive financial planning. By protecting your family’s financial future, life insurance offers peace of mind, knowing that your loved ones will be taken care of in the event of your untimely passing. It’s not solely about leaving behind a legacy, but also ensuring that your family can maintain their standard of living, pay off debts, and cover end-of-life expenses without financial burden. - 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
Financial security is one of the most important aspects of modern family life. Ensuring that loved ones are protected and well-supported in the event of an untimely death is a fundamental concern for many Australians. - read more
Life insurance is a financial product designed to provide peace of mind by offering a safety net for your loved ones in the event of your passing. The primary purpose of life insurance is to ensure that your family is financially protected, allowing them to maintain their standard of living even without your income. - read more
Knowledgebase
Claim Adjuster: An insurance professional who investigates and evaluates insurance claims to determine the amount the insurance company should pay.
No comments yet. Be the first to share your thoughts.