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.
The Australian Competition and Consumer Commissions final monitoring report on the cyclone reinsurance pool has delivered a mixed message for rural and regional northern Australia. The pool appears to have helped ease some premium pressure for medium to high cyclone-risk areas, including reductions across home, strata and small business building and contents cover. For farm families and agribusinesses in cyclone-exposed regions, that is welcome news after years of rising costs and limited choice. - read more
The Insurance Council of Australia’s redrafted General Insurance Code of Practice has moved into consultation, with submissions open until 21 July 2026 and a transition period of around two years expected if the code proceeds. For trade business owners, the headline change is that key insurer commitments are intended to become contractually enforceable, rather than sitting only as industry standards. - read more
Queensland trade businesses have received a welcome measure of cost certainty, with WorkCover Queensland’s average premium rate to remain unchanged for the 2026-27 financial year. The rate will stay at $1.343 per $100 of wages, marking the second consecutive year without an increase. - read more
Artificial intelligence is no longer a side project for technology teams. Fresh industry reporting on Clyde & Co’s Corporate Risk Radar 2026 points to a sharp rise in concern among business leaders, with technology risk now being treated as a core governance, regulatory and reputational issue. For Australian consultants, advisers, designers, engineers, accountants, marketers and other professional service providers, that shift has direct implications for risk management and professional indemnity cover. - read more
Vero has launched a new residential strata insurance product that could prove important for schemes finding it difficult to secure suitable cover, particularly in higher-risk northern markets. The product, introduced on 22 June 2026, is initially available in selected postcodes across Far North Queensland, from Bundaberg North, and Darwin, with a staged national rollout planned over the next year. - read more
Life is an unpredictable journey filled with twists and turns that can challenge even the most prepared among us. Sudden illnesses and unexpected injuries are just some of the uncertainties that can disrupt the harmony of family life. The emotional turmoil brought on by these circumstances is often compounded by the financial strain they can cause. It's during these trying times that the true value of peace of mind becomes clear. - read more
Life insurance remains one of the most crucial considerations for new parents aspiring to provide a secure future for their growing families. The arrival of a child marks a transformative moment, redefining priorities and responsibilities. At its core, life insurance is a safety net, designed to offer financial protection and stability to loved ones in the event of an unforeseen tragedy. - read more
When it comes to financial planning, life insurance often takes a backseat. Many married couples in Australia overlook its importance, thinking that it's not immediately necessary or that they can simply put it off for later. However, life insurance should be regarded as a cornerstone of a solid financial strategy. - read more
There's often confusion surrounding the amount of life insurance one truly needs. Common misconceptions cloud our judgment, leading some to undervalue their coverage, while others may overinsure, unnecessarily straining their financial resources. It is a delicate balance to strike, and understanding the nuances of life insurance is pivotal to making informed decisions. - 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
Knowledgebase
Proximate Cause: The primary cause of loss in an insurance claim, which sets in motion a chain of events leading to the damage or injury.
No comments yet. Be the first to share your thoughts.