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 latest review of the Life Insurance Code of Practice has put mental health cover at the centre of the national conversation about life insurance, disability insurance and income protection. Independent reviewer Peter Kell has completed his final report, outlining 85 recommendations aimed at improving customer protections, claims handling, communication, vulnerability support and the enforceability of the Code. - read more
APRAs latest update to the general insurance reinsurance framework may sound like a back-office regulatory change, but it has practical relevance for Australian boat owners watching premiums, excesses and renewal conditions. Published on 7 July 2026, the reforms are designed to give general insurers better access to alternative reinsurance arrangements while keeping safeguards in place for policyholders. - read more
New analysis released by the Insurance Council of Australia has put renewed attention on a major cost pressure for NSW businesses: the emergency services levy, commonly known as the ESL. The levy is currently collected through insurance premiums, meaning businesses that choose to insure their assets can face a higher cost for doing so. - read more
New modelling released on 7 July 2026 has added momentum to the debate over how New South Wales funds emergency services, with analysis suggesting that removing the Emergency Services Levy from insurance premiums could deliver meaningful savings for many households and businesses. The findings, commissioned by the Insurance Council of Australia and prepared by Lateral Economics, support a shift away from loading the cost onto insurance policies and towards a broader property-based funding model. - read more
A new cybercrime update has put a timely spotlight on a risk that many beauty businesses still treat as secondary to slips, burns, allergic reactions or damaged equipment. The Australian Institute of Criminologys latest Cybercrime in Australia report, released on 30 June 2026 and covered by Insurance Business Australia, found that cyber insurance uptake has fallen even as online threats remain widespread. - read more
Life insurance serves as a crucial safety net, guarding your loved ones against the unforeseen. Just as you would take care of your health through regular check-ups, it is equally important to ensure that your life insurance policy remains in sound condition to provide the necessary protection. - 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
Estate planning is a critical process that often goes overlooked, but it's essential for securing the financial future of your loved ones and ensuring your assets are distributed according to your wishes. It involves the careful organization and protection of an individual’s estate to minimize uncertainties and facilitate the smooth transfer of assets after their passing. While it may seem complex, understanding the basics of estate planning is necessary for every Australian adult, regardless of wealth. - read more
Financial security is one of the most important aspects of modern family life. Ensuring that loved ones are protected and well-supported in the event of an untimely death is a fundamental concern for many Australians. - 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
Knowledgebase
Income Insurance: Insures your income in the event of you being unable to work due to sickness or accident.
No comments yet. Be the first to share your thoughts.