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.
New Zealands latest insurance dispute figures are a timely warning for anyone relying on personal cover to protect their household income. The Insurance & Financial Services Ombudsman Scheme reported that, for the year ended 30 June 2026, health insurance became the largest category of disputes it investigated for the first time, with health disputes up 91 percent and 833 dispute investigations completed across all categories. - read more
The 2026 National Truck Accident Research Centre major incident report gives Australian truck operators a useful, if challenging, snapshot of where serious heavy vehicle risk is changing. Released in October 2026 and based on de-identified NTI-insured heavy vehicle major-loss claims, the report points to progress on distraction and fatigue, while also highlighting renewed concern about inappropriate speed and following distance. - read more
A federal parliamentary inquiry into small business insurance has pushed back its reporting timetable, extending the wait for recommendations on insurance affordability, availability and regulation. Insurance News reported on 27 October 2026 that the inquiry, which had been expected to report that day, now intends to table its final report by 26 February 2027 after receiving extensive evidence from across the market. - read more
Australias proposed overhaul of the General Insurance Code of Practice has moved from consultation to regulator review, with the Insurance Council of Australia lodging a strengthened code with ASIC on 22 October 2026. For shop owners, this is not an instant change to policy terms, but it is a significant development in how insurers may be expected to handle claims, complaints, vulnerability and customer communication in the next phase of the market. - read more
New research from specialist insurer CFC, reported on 26 October 2026, has put a sharper number on a problem many Australian small businesses already sense: cyber risk is moving faster than insurance take-up. CFCs local findings indicate seven in 10 Australian SMEs surveyed experienced a cyber incident in the past three years, while standalone cyber policy uptake is still estimated at only 10% to 15%. - 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
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
Life insurance premiums in Australia are shaped by a mix of personal, health, lifestyle and policy choices. This guide explains the main cost factors, how underwriting works, and why quotes can vary between insurers. - read more
Life insurance remains one of the most crucial considerations for new parents aspiring to provide a secure future for their growing families. The arrival of a child marks a transformative moment, redefining priorities and responsibilities. At its core, life insurance is a safety net, designed to offer financial protection and stability to loved ones in the event of an unforeseen tragedy. - 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
Knowledgebase
Liability Insurance: Insurance that provides protection from claims arising from injuries or damage to other people or property
No comments yet. Be the first to share your thoughts.