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

What NZ’s snow injury surge says about protecting your pay

21 Jul 2026: Paige Estritori

New Zealand’s winter injury data is a timely reminder that a day off can become a financial event very quickly. Insurance Business has reported that snow sports injury claims reached a five-year high, with ACC accepting 8,309 skiing claims at a cost of $32 million and 5,425 snowboarding claims at a cost of $14 million for 2025. For households that rely on regular wages, the issue is not only the medical bill. It is the income interruption that can follow. - read more

What a Policy Access Dispute Means for Income Protection Customers

21 Jul 2026: Paige Estritori

A recent New Zealand life insurance dispute has put a practical but often overlooked issue in the spotlight: having cover is only part of financial protection. Policyholders also need to know who owns the policy, how documents can be accessed, and what happens when urgent health circumstances arise. - read more

Netstrata Proceedings Put Strata Insurance Governance Back Under the Microscope

18 Jul 2026: Paige Estritori

NSW Fair Trading’s criminal proceedings against Network Strata Services Pty Ltd, trading as Netstrata, have pushed strata governance and insurance transparency back into the national spotlight. The regulator alleges the company and its director and licensee in charge breached statutory obligations connected with strata scheme management in New South Wales, including alleged failures around conflicts of interest, undisclosed financial benefits and information provided to the regulator. - read more

Broker Disclosure Debate Puts Small Business Questions Back on the Table

18 Jul 2026: Paige Estritori

A fresh dispute over the proposed Insurance Brokers Code of Practice has sharpened the focus on transparency for Australian small businesses. Industry figure John Trowbridge has criticised gaps in the draft code, particularly around whether brokers should disclose commissions and other remuneration to all clients, not only those captured by narrower product or client categories. - read more

AFCA Income Protection Decision Highlights a Hidden Risk for Variable Earners

18 Jul 2026: Paige Estritori

A recent Australian Financial Complaints Authority decision has put a spotlight on a detail that can be easy to overlook: how an income protection policy defines income. In the case, a policyholder receiving payments under an employer-arranged group income protection policy argued that regular sales commissions should be counted when calculating his pre-disability income. - read more

Click for more Insurance News