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.â€
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.â€
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.
Recent transport industry coverage has again highlighted regulator attention on heavy vehicle roadworthiness, with roadside checks, defect management and maintenance systems remaining central safety themes for Australian operators. For trucking businesses, the message is not limited to avoiding fines or delays. Roadworthiness can also influence how insurers view risk, how smoothly a claim progresses and whether policy conditions have been met after an incident. - read more
Australia’s engineered stone ban and continuing regulator focus on silica exposure are more than a workplace safety issue for builders, renovators, tilers, stonemasons, plumbers, electricians and demolition contractors. They also create a practical insurance checkpoint for any trade business that cuts, drills, grinds, removes or works around dust-generating materials. - read more
Fresh motor insurance commentary across the Australian market is again pointing to a practical issue truck operators know well: repairing vehicles is becoming more complex, more expensive and, in some cases, slower. For heavy vehicle businesses, this is not just a workshop problem. It can influence claim outcomes, renewal pricing, excess settings and the amount of time a truck is off the road after an incident. - read more
Recent complaints data from the Australian Financial Complaints Authority has again highlighted a pressure point that matters to rural Australia: insurance claims can become difficult when expectations, policy wording and evidence do not line up. While the figures cover the wider insurance market rather than farms alone, the themes are highly relevant for agricultural businesses dealing with storm damage, fire losses, machinery failures, fencing repairs or interrupted operations. - read more
Fresh industry attention on ASIC's expectations for compensation arrangements is a timely reminder that professional indemnity insurance should not be treated as a once-a-year renewal task. For Australian professionals who provide advice, compliance support, financial services, consulting, design, technology or outsourced business services, the adequacy of cover depends on how closely the policy matches the work actually being performed. - 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
Life insurance serves as a crucial safety net, guarding your loved ones against the unforeseen. Just as you would take care of your health through regular check-ups, it is equally important to ensure that your life insurance policy remains in sound condition to provide the necessary protection. - 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
Life insurance is an essential financial protection that provides peace of mind to policyholders and their loved ones. The premiums you pay are determined by various factors, including age, health, lifestyle, and occupation. - 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
Knowledgebase
Replacement Cost: The amount it would cost to replace or rebuild an insured asset with one of similar kind and quality, without depreciation.
No comments yet. Be the first to share your thoughts.