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.

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.

Published:Friday, 1st Nov 2024
Author: Paige Estritori

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.

Share this news item:

Insurance News

Clear

Farm Insurance Pressure Builds as Affordability Concerns Return

12 Aug 2026: Paige Estritori

Renewed rural industry attention on insurance affordability is a timely warning for Australian farm businesses preparing for renewal season. Premium pressure is not only a household issue in regional areas; it can affect the commercial reality of running a farm, from insuring sheds and machinery to protecting stored produce, livestock infrastructure and liability exposures. - read more

What the Life Insurance Code review means for policyholders

12 Aug 2026: Paige Estritori

The continuing review of Australia's Life Insurance Code of Practice has become more than an industry governance exercise. For policyholders, it is a timely reminder that the real value of life insurance depends on what happens at underwriting, at renewal, and especially when a claim is made. - read more

Cyclone Cover Debate Highlights Strata Insurance Pressure Points

12 Aug 2026: Paige Estritori

The latest industry attention on Australia's cyclone reinsurance arrangements is a timely reminder that premium relief for strata schemes is rarely driven by one policy lever alone. The cyclone pool was designed to reduce insurer exposure to cyclone-related losses in higher-risk regions, particularly across northern Australia. However, for owners corporations and body corporates, the practical impact can still vary sharply from building to building. - read more

Why Apartment Defect Scrutiny Matters for Strata Insurance

12 Aug 2026: Paige Estritori

Renewed attention on apartment building defects is a timely reminder that strata insurance is not assessed in isolation from the physical condition of a scheme. For owners corporations and body corporates, the issue is not only whether cover is in place, but whether the building can be clearly presented to insurers as a well-managed and understood risk. - read more

Insurance Complaint Trends Put Policy Clarity Back in Focus

12 Aug 2026: Paige Estritori

Fresh complaints data from the Australian Financial Complaints Authority has again put pressure on the general insurance sector, with policy disputes, delays and communication breakdowns remaining a major source of frustration for customers. For Australian tradies, the headline is not just that complaints are being lodged; it is that many disputes appear to begin with mismatched expectations between what a policyholder thought was covered and how the insurer interpreted the wording when a claim arrived. - read more

Click for more Insurance News