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.
A recent quad bike fatality case in New South Wales has put farm safety, workplace liability and risk management back under close attention. ABC Rural reported on 2 July 2026 that Wumbulgal Agriculture Pty Ltd was fined $555,000 after an 82-year-old worker died in a quad bike accident at Yenda in the Riverina in February 2023. The company was found to have breached work health and safety obligations. - read more
The Department of Veterans’ Affairs has confirmed a significant change to the way allied health care for eligible veterans will be funded from 1 July 2027. The reform combines higher provider fees with the removal of the current treatment cycle and the introduction of a $5,000 annual allied health expenditure threshold for review of clinical effectiveness. - read more
The Insurance Council of Australia has opened public consultation on a redrafted General Insurance Code of Practice, with feedback invited from 24 June 2026 until 21 July 2026. For fitness professionals, this is more than an insurance-sector process. It is a timely reminder that the value of a policy is tested not only by the premium, but by what happens when a claim, complaint or vulnerable customer situation arises. - read more
APRA’s latest move on insurance data may sound technical, but it has practical implications for Australian consultants reviewing their risk programmes. The regulator has confirmed it will separately publish cyber insurance and management liability data within the National Claims and Policies Database, rather than leaving those lines blended into broader liability categories. - read more
A new crane and rigging insurance facility in Australia has put a spotlight on a practical problem that many high-risk contractors already understand: when one job is insured across several policies, a loss can become a dispute about which insurer should respond. - read more
Financial security for families is an essential consideration in any household. Life can be unpredictable, and ensuring that your loved ones are protected from financial hardship in your absence is a critical part of financial planning. - read more
For many Australian families, the concept of estate planning might evoke imagery of vast wealth and complex legal documents, reserved for the very affluent. However, this misconception overshadows the universal importance of having an estate plan, which at its core, is about ensuring your loved ones are cared for and your wishes are honored upon your passing—even if you don't consider yourself wealthy. - read more
Life insurance is a financial product designed to provide peace of mind by offering a safety net for your loved ones in the event of your passing. The primary purpose of life insurance is to ensure that your family is financially protected, allowing them to maintain their standard of living even without your income. - read more
Life insurance is a critical component of a sound financial plan. It provides financial security and peace of mind to you and your loved ones, ensuring that they are taken care of in the event of your untimely death. - 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.