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.
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
Victoria has moved another step in its building reform program, with the Building and Plumbing Commission now operating with stronger consumer protection powers and a developer bond scheme scheduled for apartment buildings from 1 July 2027. For strata communities, the announcement is not simply a construction law update. It is a reminder that building quality, defect management and insurance planning are becoming increasingly connected. - read more
A recent Australian Financial Complaints Authority decision has delivered a timely reminder for small operators: insurance protection depends on the details being right before something goes wrong. The dispute involved a food delivery business that suffered theft and damage at a site that was not listed on its insurance schedule. - read more
Australia’s insurance broking sector is again facing scrutiny over how clearly small business clients are told about broker remuneration. The latest debate follows the release of a draft update to the Insurance Brokers Code of Practice, after earlier recommendations had supported broader disclosure of fees and commissions to individual and small business clients across more insurance products. - 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
Life insurance is a financial product that provides a lump sum payment to your beneficiaries in the event of your death. It is designed to offer financial security by covering debts, daily living expenses, and future financial obligations. - read more
Single parenting brings with it a mosaic of responsibilities and challenges, not least of which is securing a stable financial future for your child. The rollercoaster of raising a child alone often means that planning for the future can take a back seat to the day-to-day demands of parenting. Unexpected illnesses and injuries can compound these challenges, causing stress to multiply and plans to go awry. - read more
Defining life insurance and its importance: Life insurance is a pivotal financial product designed to protect your loved ones from economic hardship in case of your untimely death. It acts as a safety net, ensuring that your family can maintain their standard of living, cover outstanding debts, and afford future expenses like education and retirement. - read more
Life insurance is a financial product designed to provide a safety net for your loved ones and business in the event of your passing. At its core, life insurance aims to deliver financial protection by paying out a lump sum or ongoing payments to a designated beneficiary upon the insured's death. - read more
Knowledgebase
Insurance Deductible: the amount that an insured is required to contribute toward an insurance claim as stipulated in an insurance policy. Otherwise known as the "policy excess".
No comments yet. Be the first to share your thoughts.