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.â€
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.â€
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.
Fresh attention on cyber incidents across Australian businesses is a timely warning for restaurants, cafés and takeaway operators. Hospitality venues may not always see themselves as data-heavy businesses, but modern food service increasingly depends on connected systems: point-of-sale terminals, booking platforms, delivery apps, QR ordering, loyalty databases, rostering tools and cloud accounting. - read more
Recent heavy vehicle compliance activity has again put fatigue management near the top of the risk agenda for Australian transport operators. While enforcement is usually framed as a road safety issue, it also has a direct insurance dimension. Insurers assessing truck insurance risk increasingly look beyond the vehicle itself and ask how well the business controls driver behaviour, scheduling pressure, maintenance downtime and record-keeping. - read more
APRA’s latest general insurance data has again highlighted a point many Australian tradies are already feeling at renewal time: a healthier insurance sector does not necessarily translate into simple or immediate premium relief for small businesses. While insurers continue to operate with stronger capital buffers and improved underwriting discipline, the costs sitting behind many policies remain under pressure. - read more
Fresh complaints reporting from the Australian Financial Complaints Authority has put insurance service standards back under the microscope, with claim delays, communication issues and disputed outcomes continuing to feature in the wider financial services complaints landscape. For beauty salon owners, skin clinics, nail technicians and mobile beauticians, the lesson is practical: the moment a loss occurs is not the best time to discover that records are incomplete, policy wording is unclear or a treatment has not been properly disclosed. - read more
New South Wales insurance buyers may be heading for an important change as reform of the Emergency Services Levy continues to attract attention across the insurance sector. The levy has long been added to many insurance premiums in NSW to help fund emergency services, and insurers have argued that this approach makes cover more expensive for households and businesses that choose to insure. - read more
Life insurance is designed to provide financial support to your loved ones if you pass away. For Australian families, it can help cover debts, everyday living costs, funeral expenses and future needs such as children's education. This guide explains how life insurance works, what affects premiums, how to estimate cover, and what to check before choosing or maintaining a policy. - read more
A life insurance claim usually involves notifying the insurer, confirming the policy and beneficiaries, providing evidence such as a death certificate or medical information, and waiting for the insurer or super fund trustee to assess the claim. - 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
Navigating the complex world of insurance can often feel daunting, but understanding the importance of life stage consideration when choosing life insurance is essential. As we journey through the various chapters of our lives, our financial responsibilities, dependents, and personal circumstances evolve. These changes invariably have significant implications for our insurance needs. - read more
Life insurance is a financial product designed to provide a safety net for your loved ones and business in the event of your passing. At its core, life insurance aims to deliver financial protection by paying out a lump sum or ongoing payments to a designated beneficiary upon the insured's death. - read more
Knowledgebase
Deductible: The amount you must pay out-of-pocket for expenses before your insurance company covers the remaining costs.
No comments yet. Be the first to share your thoughts.