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.
A federal parliamentary inquiry into small business insurance has reportedly pushed back its final report from 27 October 2026 to 26 February 2027, extending the wait for recommendations on insurance affordability, availability and regulation. For Australian tradies and small trade businesses, the delay matters because the inquiry is examining the types of cover many operators rely on daily, including public liability, professional indemnity, cyber risk and business interruption insurance. - read more
A new Insurance Brokers Code of Practice has been launched by the National Insurance Brokers Association, putting clearer disclosure, renewal contact and client support standards on the agenda for Australian businesses that use brokers to arrange cover. The 2027 Code takes effect on 1 January 2027 and is designed to set out, in plainer language, what clients should be able to expect from subscribing insurance brokers. - read more
The Australian Financial Complaints Authoritys latest annual review has put income protection insurance back in focus, with the product again attracting the highest number of life insurance complaints in 2025-26. The figures are a useful reminder that the real value of cover is tested not at purchase, but when illness or injury interrupts a persons capacity to earn. - read more
A recent Australian Financial Complaints Authority determination involving a flooded farmhouse has put claims handling back under the microscope for rural policyholders, after the insurer was ordered to pay almost $432,000 across building repairs, additional temporary accommodation, professional costs and compensation for non-financial loss. The decision, dated 27 August 2026 and reported by Insurance News on 15 October 2026, is a useful reminder that the practical aftermath of a farm flood can extend well beyond the first clean-up. - read more
A recent Australian Financial Complaints Authority decision involving a vandalised Hino truck is a useful reminder that disclosure disputes in commercial motor insurance turn on evidence, not assumptions. Reported by insuranceNEWS.com.au on 15 October 2026, the matter ended with Suncorp being ordered to reinstate the policy and reassess the claim after AFCA found the insurer had not proved that undisclosed driving history would have justified refusing the risk. - read more
The importance of life insurance in financial planning: Life insurance isn’t just a policy; it’s a cornerstone of comprehensive financial planning. By protecting your family’s financial future, life insurance offers peace of mind, knowing that your loved ones will be taken care of in the event of your untimely passing. It’s not solely about leaving behind a legacy, but also ensuring that your family can maintain their standard of living, pay off debts, and cover end-of-life expenses without financial burden. - read more
A life insurance claim usually involves notifying the insurer, confirming the policy and beneficiaries, providing evidence such as a death certificate or medical information, and waiting for the insurer or super fund trustee to assess the claim. - read more
Life insurance is designed to provide financial support to your loved ones if you pass away. For Australian families, it can help cover debts, everyday living costs, funeral expenses and future needs such as children's education. This guide explains how life insurance works, what affects premiums, how to estimate cover, and what to check before choosing or maintaining a policy. - 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 a financial product that provides a lump sum payment to your beneficiaries in the event of your death. It is designed to offer financial security by covering debts, daily living expenses, and future financial obligations. - read more
Knowledgebase
Underwriting: The process by which an insurer determines the risk of insuring a client and decides the terms of coverage.
No comments yet. Be the first to share your thoughts.