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

Income Protection Complaints Remain a Key Life Insurance Pressure Point

28 Oct 2026: Paige Estritori

The Australian Financial Complaints Authority’s latest annual review has put income protection insurance back in focus, with the product again attracting the highest number of life insurance complaints in 2025-26. The figures are a useful reminder that the real value of cover is tested not at purchase, but when illness or injury interrupts a person’s capacity to earn. - read more

Farm Flood Dispute Shows the Cost of Delayed Claims Handling

28 Oct 2026: Paige Estritori

A recent Australian Financial Complaints Authority determination involving a flooded farmhouse has put claims handling back under the microscope for rural policyholders, after the insurer was ordered to pay almost $432,000 across building repairs, additional temporary accommodation, professional costs and compensation for non-financial loss. The decision, dated 27 August 2026 and reported by Insurance News on 15 October 2026, is a useful reminder that the practical aftermath of a farm flood can extend well beyond the first clean-up. - read more

Truck Claim Dispute Shows Disclosure Evidence Matters

24 Oct 2026: Paige Estritori

A recent Australian Financial Complaints Authority decision involving a vandalised Hino truck is a useful reminder that disclosure disputes in commercial motor insurance turn on evidence, not assumptions. Reported by insuranceNEWS.com.au on 15 October 2026, the matter ended with Suncorp being ordered to reinstate the policy and reassess the claim after AFCA found the insurer had not proved that undisclosed driving history would have justified refusing the risk. - read more

Why rising builder failures matter for contract works cover

17 Sep 2026: Paige Estritori

Australia's construction sector remains under pressure, with recent insolvency figures continuing to show building and construction as one of the most exposed parts of the economy. Higher material costs, tight margins, labour shortages, delayed payments and fixed-price contract stress have all contributed to a tougher operating environment for builders, subcontractors and project owners. - read more

How Softer Truck Sales Can Affect Insurance Decisions

17 Sep 2026: Paige Estritori

Recent transport industry sales updates point to a more selective new-truck market, with operators weighing replacement timing against finance costs, emissions planning, availability and contract confidence. For truck businesses, that matters well beyond the showroom. A change in buying momentum can flow through to vehicle values, repair economics, insurer appetite and the way fleets should set insurance sums before renewal. - read more

Click for more Insurance News