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.
Quay Marine Insurance has been appointed as a Coverholder for XL Insurance Company SE (XLICSE), a subsidiary of AXA XL, marking a significant milestone in its mission to provide tailored marine insurance solutions across Australia. - read more
Insurance Australia Group (IAG) has reached a confidential settlement in the $4 billion lawsuit initiated by Greensill Bank AG and its insolvency administrator. This legal action stemmed from disputes over insurance coverage related to Greensill's financial products. - read more
A recent analysis by Macquarie has revealed a significant decline in the domestic business package market share held by Australian insurers, dropping to approximately 48% in the fiscal year 2025 from nearly 67% a decade ago. - read more
Suncorp has successfully secured up to AU$2.4 billion in reinsurance protection over five years, leading to a significant 10% increase in its share value. This strategic move is expected to bolster the company's fiscal 2026 growth outlook, with projected gross written premium growth of 3% across its Australia and New Zealand operations. The reinsurance arrangement, effective from June 30, is designed to cap natural hazard costs in approximately 90% of scenarios, thereby reducing earnings volatility. - read more
The Australian cosmetic nursing industry has experienced significant growth, driven by increasing demand for non-surgical cosmetic procedures such as injectables and skin treatments. This expansion has led to heightened scrutiny and the implementation of new regulations aimed at ensuring patient safety and professional accountability. - read more
Life insurance might not be at the forefront of your mind, especially when you're young and healthy. However, understanding the essence of life insurance early on can significantly impact your financial future and provide much-needed peace of mind. - read more
Life insurance is an essential financial protection that provides peace of mind to policyholders and their loved ones. The premiums you pay are determined by various factors, including age, health, lifestyle, and occupation. - 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
Shareholder agreements lay the cornerstone for stable business relationships and continuity in Australia. Acting as a contract among business owners, these agreements set forth the expectations, rights, and obligations of all parties involved. They are particularly vital in delineating clear paths for dispute resolution, succession planning, and the transfer of ownership shares under varied circumstances, including the untimely death or departure of a shareholder. - 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
Knowledgebase
Elimination Period: The time period between an injury and the receipt of benefit payments from an insurer, particularly in disability insurance.
No comments yet. Be the first to share your thoughts.