Insurer Must Pay After Unfounded Fraud Allegations
Insurer Must Pay After Unfounded Fraud Allegations
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.
A leading insurance company has been ordered to cover a fire damage claim submitted by a policyholder who passed away from cancer two years ago, highlighting the consequences of unjust fraud accusations.
The claim was initially submitted in January 2022 for damage incurred to the man’s remote metal home in New South Wales. The insurer denied the claim on the grounds that the property was fraudulently misrepresented in terms of its status and functionality.
The policyholder, under heavy medication due to his illness, was questioned by the insurance company’s investigators. Unfortunately, he passed away roughly five months following the submission of the insurance claim. His estate's executor took over the complaint afterwards.
Recently, the Australian Financial Complaints Authority (AFCA) determined that the insurer, IAG, did not provide adequate evidence showing that the policyholder had breached his disclosure commitments. Thus, they must honour the claim.
According to AFCA, “Even if there had been a breach, the insurer has not convincingly shown that it resulted in the renewal of the policy when it would not have been otherwise. Thus, it is fair that the insurer accepts the claim.”
AFCA pointed out that IAG did not submit a declaration from its underwriters to either prove it would not have undertaken or renewed the policy. Despite cautions regarding potential adverse inferences, the insurer failed to provide necessary documentation on its underwriting practices pertaining to this case.
Originally, IAG contended that the policyholder had wrongly described the condition of his property upon policy initiation in October 2019, claiming it was watertight, structurally sound, secure, well-maintained, and inclusive of functional kitchen and bathroom facilities, and specifying its construction date as approximately 2019.
The policy contained a clause explicitly stating, “We don’t insure buildings under initial construction.”
AFCA’s investigation found that, as of the relevant policy renewal date in October 2021, the property's construction was completed, and it had been continuously occupied for over a year, meeting structural and maintenance codes.
“Each renewal constituted a new insurance contract,” the ombudsman declared.
Moreover, AFCA emphasized that the allegation of fraud, which carries grave implications, wasn’t sufficiently supported given that for a misrepresentation to amount to fraud, it must be made either knowingly or recklessly.
EVEN if I had determined that the policyholder breached the disclosure duty-which I have not-the insurer did not provide necessary proof to show it would not have entered the 2021-22 policy period without the alleged breach,” AFCA noted.
In their ruling, AFCA also highlighted the insurance contract and product disclosure statements omitted critical information regarding the duty to avoid misrepresentation, relevant disclosure duties, or consequences of any such breaches.
For more information on the ruling, it can be reviewed here.
This article has been adapted from one originally published by Insurance News Magazine.
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.
More Australian insurers are now recognising household bushfire resilience ratings, a development rural and regional property owners should watch closely as risk-based pricing becomes more visible across the insurance market. NAB and CommBank insurance brands have joined the program, alongside existing participants including NRMA Insurance and Suncorp, meaning a significant share of the home insurance market is now engaging with assessed bushfire mitigation. - read more
PSC Insurance Brokers’ investment in MA Insurance Brokers is a timely reminder that specialist transport insurance advice is becoming increasingly valuable in a tighter, more complex market. The deal, announced in late June 2026, sees MA begin operating as PSC Transport Insurance Brokers, while founders Barry Mathison and Mariann Illyes retain an equity stake and continue leading the business as managing principals. - read more
QBE’s decision to stop offering its standalone office and trade pack products from July 2026 is a timely reminder for Australian tradies to treat every renewal as more than a simple rollover. The insurer is moving customers towards a standard business cover structure, with existing trade pack policyholders expected to be offered the replacement product at renewal from October 2026. - read more
Road user charging is moving from policy theory to a more serious industry conversation, with a new ITS Australia survey pointing to growing support for replacing fuel excise with a distance-based funding model. For transport operators, this is not just a tax discussion. It could change how fleets calculate running costs, compare vehicle types and plan margins on long-term freight contracts. - read more
A recent Australian Financial Complaints Authority decision is a timely warning for trade businesses that rely on tools, trailers and mobile equipment every day. The dispute centred on a business that had tools and a trailer stolen from a worksite, then challenged the insurer’s payout after discovering the claim was limited by the portable items section of the policy. - read more
Single parenting brings with it a mosaic of responsibilities and challenges, not least of which is securing a stable financial future for your child. The rollercoaster of raising a child alone often means that planning for the future can take a back seat to the day-to-day demands of parenting. Unexpected illnesses and injuries can compound these challenges, causing stress to multiply and plans to go awry. - read more
Navigating the complex world of insurance can often feel daunting, but understanding the importance of life stage consideration when choosing life insurance is essential. As we journey through the various chapters of our lives, our financial responsibilities, dependents, and personal circumstances evolve. These changes invariably have significant implications for our insurance needs. - read more
Life is a tapestry of precious moments, each framed by the inevitable uncertainty that the future holds. The awareness that our paths are peppered with unpredictability can often cast a shadow of concern, affecting how we cherish the present. For many, the well-being of family remains the cornerstone of life's purpose, driving the need for a foundation that offers stability and reassurance in the face of life's unexpected challenges. - 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
Defining life insurance and its importance: Life insurance is a pivotal financial product designed to protect your loved ones from economic hardship in case of your untimely death. It acts as a safety net, ensuring that your family can maintain their standard of living, cover outstanding debts, and afford future expenses like education and retirement. - read more
Knowledgebase
Copayment: A fixed amount you pay for a covered healthcare service, usually when you receive the service.
No comments yet. Be the first to share your thoughts.