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.
A damaging hailstorm across Victoria’s Mallee has turned a promising harvest into a difficult insurance and cash-flow test for affected grain growers. ABC Rural reported on 6 November 2026 that hail swept through districts including Birchip, Wycheproof and Quambatook, damaging thousands of hectares of wheat, barley, lentils, canola and other crops just as many paddocks were ready to harvest. - read more
A recent Australian Financial Complaints Authority decision has highlighted a difficult but common issue for strata communities: damage that happens during a storm is not always insured storm damage. The dispute, reported on 5 November 2026, involved an owners corporation claim for a collapsed parapet wall, with the insurer declining cover on the basis that defective design, materials or workmanship were the dominant cause rather than the weather event itself. - read more
A new Australian healthcare professional liability market update points to a sharper divide between general insurance market conditions and the experience of healthcare organisations arranging malpractice and professional liability cover. Lockton’s 1 November 2026 update says established insurers remain selective, claims inflation is affecting attachment points and underwriters are looking more closely at how clinical governance works in practice, not merely whether accreditation exists. - read more
Western Australia’s updated Working With Children Check laws are a timely reminder that fitness business risk is not limited to physical injury, equipment damage or venue incidents. The changes, in effect from 17 September 2026 and highlighted by AUSactive in October, mean certain adverse Working With Children outcomes from other Australian jurisdictions can now affect a person’s ability to work with children in WA. - read more
APRA’s latest comments on artificial intelligence in insurance have shifted attention from future technology to a practical issue for today’s small operators: the quality of the information insurers use to understand risk. For domestic and home service businesses, sharper underwriting could eventually mean more tailored pricing, but it may also make incomplete records, unclear operations or higher-risk work harder to overlook. - read more
Shareholder agreements lay the cornerstone for stable business relationships and continuity in Australia. Acting as a contract among business owners, these agreements set forth the expectations, rights, and obligations of all parties involved. They are particularly vital in delineating clear paths for dispute resolution, succession planning, and the transfer of ownership shares under varied circumstances, including the untimely death or departure of a shareholder. - read more
Life insurance is an essential financial protection that provides peace of mind to policyholders and their loved ones. The premiums you pay are determined by various factors, including age, health, lifestyle, and occupation. - 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
Trauma insurance, also known as critical illness insurance, is a type of coverage that provides a lump sum payment in the event that the insured suffers from a critical illness or injury. Unlike health insurance, which covers medical expenses, trauma insurance is designed to provide financial protection by helping to cover the additional costs associated with recovery from a severe illness or injury. - 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
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.