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

New Isuzu Truck Recall Highlights a Claims Evidence Issue

05 Nov 2026: Paige Estritori

A fresh safety recall affecting 3,710 Isuzu MY25 trucks is a timely reminder that modern truck insurance risk is not only about driver behaviour, road conditions or workshop servicing. Software, trailer systems and electronic braking signals can all become part of the evidence trail if an incident occurs. - read more

Mental Health Cover Debate Now Matters for Business Protection

05 Nov 2026: Paige Estritori

Australia’s life insurance sector is moving into a detailed debate over how mental health conditions should be treated in disability-style cover, and the outcome could matter for business owners who rely on insurance to protect income, debt and operational continuity. - read more

Life Claims Inquiry Puts Delays Under Fresh Scrutiny

05 Nov 2026: Paige Estritori

A new Life Code Compliance Committee inquiry has put renewed attention on how Australian life insurers manage longer-running claims, finding that avoidable gaps in information requests and customer communication can add pressure to already complex total and permanent disability and income protection matters. - read more

New claims data puts life insurance dispute risk back in focus

05 Nov 2026: Paige Estritori

Australian life insurance claims performance is back under scrutiny after APRA released its latest Life Insurance Claims and Disputes Statistics on 16 October 2026, covering the rolling 12 months from 1 July 2025 to 30 June 2026. ASIC’s MoneySmart claims comparison tool was also updated on 26 October 2026, giving consumers and business owners a clearer way to compare insurers by accepted claims, decision times, disputes and cancellation rates. - read more

Claims review highlights the cost of slow communication

05 Nov 2026: Paige Estritori

A new Life Code Compliance Committee inquiry has sharpened attention on how life insurers manage longer-running total and permanent disability and income protection claims, finding that earlier information requests and clearer communication could reduce avoidable delays for people already dealing with illness, injury or loss of income. - read more

Click for more Insurance News