AFCA Upholds Fair Evaluation in Insurance Claim Dispute

2

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
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

Envest Group Unveils TLI Underwriting for Heavy Motor Fleets

04 Jan 2026: Paige Estritori

Envest Group, a prominent player in Australia's insurance sector, has announced the launch of TLI Underwriting, a new agency dedicated to providing specialised insurance solutions for large truck fleets. This initiative marks a significant expansion in Envest's offerings, aiming to address the unique challenges faced by substantial fleet operators. - read more

AFCA Mandates Insurer Payout for Overheated Truck Engine Damage

04 Jan 2026: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has recently ruled in favour of a truck owner, ordering an insurer to pay out a claim for engine damage caused by overheating. This decision underscores the critical importance of clear policy terms and the responsibilities of both insurers and policyholders in the claims process. - read more

Insurers Highlight Elevated Road Risks Amid Holiday Freight Surge

04 Jan 2026: Paige Estritori

As the Australian summer school holidays approach, insurers and transport specialists are raising concerns about heightened road risks resulting from the convergence of increased holiday travel and peak freight activity. This period sees a significant uptick in both passenger vehicles and heavy trucks on the roads, amplifying the potential for accidents and necessitating heightened vigilance among all road users. - read more

Australian Super's Claim Delays Raise Concerns Among Members

03 Jan 2026: Paige Estritori

Australian Super, one of the nation's largest superannuation funds, is facing criticism over significant delays in processing insurance claims, particularly those related to income protection and total and permanent disability (TPD). Members have reported prolonged waiting periods, leading to financial hardships and uncertainty. - read more

Club Marine Revamps Commercial Boat Insurance Policies

03 Jan 2026: Paige Estritori

Club Marine, Australia's leading provider of recreational boat insurance, has announced significant enhancements to its commercial boat insurance offerings. This strategic move aims to better align commercial policies with the company's recreational insurance products, providing comprehensive coverage for vessels used in both business operations and occasional leisure activities. - read more

Click for more Insurance News