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.

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.

Published:Friday, 1st Nov 2024
Author: Paige Estritori

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.

Share this news item:

Insurance News

Clear

Victoria’s Strata Commission Debate Moves Into a New Phase

21 Jun 2026: Paige Estritori

Victoria’s strata reform agenda has taken another important turn, with consumer advocates continuing to push for a ban on insurance-related commissions paid to owners corporation managers after the state government chose to defer immediate action on the issue. - read more

Insurance Code Rewrite Could Lift Standards for Tradies

21 Jun 2026: Paige Estritori

Australian tradies could soon see an important shift in how general insurers are expected to communicate, manage claims and resolve disputes, with the industry’s General Insurance Code of Practice moving closer to a major rewrite. - read more

ASIC Warning Highlights Ongoing Delays in Super Death Benefit Claims

21 Jun 2026: Paige Estritori

ASIC’s latest warning to superannuation trustees is a timely reminder that life insurance is only as valuable as the claims process behind it. The regulator’s June 2026 progress review found that while many trustees have improved how they manage death benefit claims, some are still moving too slowly on basic service standards for grieving families. - read more

Rural Insurance Costs Face Fresh Scrutiny in Queensland

21 Jun 2026: Paige Estritori

Insurance affordability in south-west Queensland has moved from local frustration to a national competition issue, after Maranoa MP David Littleproud lodged a formal complaint with the Australian Competition and Consumer Commission over sharp premium increases across the region. - read more

Why Policy Exclusions Matter Before a Claim

21 Jun 2026: Paige Estritori

A recent Victorian Supreme Court decision is a timely reminder that having property or business interruption cover does not automatically mean every costly disruption will be insured. The case involved a glass reprocessing business whose site was taken over by Victoria’s environmental regulator in early 2020 after concerns about fire hazards, contamination and risks to public health and the environment. - read more

Click for more Insurance News