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.
The Australian Prudential Regulation Authority (APRA) has recently taken decisive action to address significant concerns within the commercial auto insurance sector. In response to widespread industry protests over substantial premium increases, APRA has introduced emergency regulations aimed at safeguarding transport operators from financial hardship. - read more
As the Australian insurance industry navigates a rapidly evolving landscape, Deloitte's 2026 Insurance Predictions report highlights two pivotal trends poised to reshape the sector: the integration of artificial intelligence (AI) and the adoption of advanced climate risk modeling. - read more
In a significant development for policyholders, leading Australian life insurer TAL has announced the expansion of its Health Sense Plus program to encompass income protection (IP) policies. Effective from 8 August 2025, this initiative aims to incentivise proactive health management by offering premium discounts to clients who engage in preventative health checks. - read more
The Australian Financial Complaints Authority (AFCA) has recently ruled in favour of a policyholder who inadvertently cancelled his critical illness insurance due to unclear communication from his insurer, TAL Life. This decision underscores the critical importance of transparent communication between insurers and their clients, particularly regarding the implications of policy modifications. - read more
AIA Australia has recently updated its Priority Protection life insurance suite, introducing changes designed to simplify discounts, enhance policy clarity, and support premium affordability. These enhancements, effective from 9 November 2025, reflect AIA's commitment to providing value-driven solutions for policyholders. - read more
Life insurance serves as a crucial safety net, guarding your loved ones against the unforeseen. Just as you would take care of your health through regular check-ups, it is equally important to ensure that your life insurance policy remains in sound condition to provide the necessary protection. - 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
Financial security for families is an essential consideration in any household. Life can be unpredictable, and ensuring that your loved ones are protected from financial hardship in your absence is a critical part of financial planning. - read more
When it comes to financial planning, life insurance often takes a backseat. Many married couples in Australia overlook its importance, thinking that it's not immediately necessary or that they can simply put it off for later. However, life insurance should be regarded as a cornerstone of a solid financial strategy. - 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
Knowledgebase
Liability Insurance: Insurance that provides protection from claims arising from injuries or damage to other people or property
