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

Surging Insurance Costs Pose Challenges for Australian Retirees

08 Apr 2026: Paige Estritori

Recent reports indicate a significant increase in insurance premiums across Australia, with some policies experiencing hikes of up to 18%. This surge is placing considerable financial pressure on retirees, many of whom are on fixed incomes and find it challenging to accommodate these rising costs. - read more

AMA Calls for Urgent Reforms in Private Health Insurance Sector

08 Apr 2026: Paige Estritori

The Australian Medical Association (AMA) has released a report indicating that private health insurance is increasingly failing to deliver value for money. The report highlights that premiums have risen sharply, outpacing inflation and wage growth, while nearly 70% of policies now contain exclusions for specific treatments or conditions. - read more

APRA Freezes Unjustified Premium Hikes in Commercial Auto Insurance

07 Apr 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has recently implemented emergency measures to address significant premium increases in the commercial auto insurance sector. This intervention comes in response to widespread industry concerns over substantial rate hikes that threaten the financial stability of transport operators across the nation. - read more

Federal Court Upholds Denial of Truck Driver's Insurance Claim

07 Apr 2026: Paige Estritori

In a recent legal development, the Federal Court of Australia dismissed an appeal by a logging truck driver, Mr. Bradley Henschke, concerning his insurance claim through the Australian Retirement Trust. The case, Henschke v Australian Retirement Trust [2026] FCA 80, highlights the critical importance of understanding the specifics of insurance coverage within superannuation accounts. - read more

Escalating Fuel Prices Pose Existential Threat to Australian Trucking Industry

07 Apr 2026: Paige Estritori

The Australian trucking industry is facing unprecedented challenges as soaring fuel prices threaten the viability of many operators. Industry leaders are urgently calling for government intervention to prevent potential supply chain disruptions that could affect the entire nation. - read more

Click for more Insurance News