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.
The Australian Competition and Consumer Commissions final monitoring report on the cyclone reinsurance pool has delivered a mixed message for rural and regional northern Australia. The pool appears to have helped ease some premium pressure for medium to high cyclone-risk areas, including reductions across home, strata and small business building and contents cover. For farm families and agribusinesses in cyclone-exposed regions, that is welcome news after years of rising costs and limited choice. - read more
The Insurance Council of Australia’s redrafted General Insurance Code of Practice has moved into consultation, with submissions open until 21 July 2026 and a transition period of around two years expected if the code proceeds. For trade business owners, the headline change is that key insurer commitments are intended to become contractually enforceable, rather than sitting only as industry standards. - read more
Queensland trade businesses have received a welcome measure of cost certainty, with WorkCover Queensland’s average premium rate to remain unchanged for the 2026-27 financial year. The rate will stay at $1.343 per $100 of wages, marking the second consecutive year without an increase. - read more
Artificial intelligence is no longer a side project for technology teams. Fresh industry reporting on Clyde & Co’s Corporate Risk Radar 2026 points to a sharp rise in concern among business leaders, with technology risk now being treated as a core governance, regulatory and reputational issue. For Australian consultants, advisers, designers, engineers, accountants, marketers and other professional service providers, that shift has direct implications for risk management and professional indemnity cover. - read more
Vero has launched a new residential strata insurance product that could prove important for schemes finding it difficult to secure suitable cover, particularly in higher-risk northern markets. The product, introduced on 22 June 2026, is initially available in selected postcodes across Far North Queensland, from Bundaberg North, and Darwin, with a staged national rollout planned over the next year. - 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
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
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 is an unpredictable journey filled with twists and turns that can challenge even the most prepared among us. Sudden illnesses and unexpected injuries are just some of the uncertainties that can disrupt the harmony of family life. The emotional turmoil brought on by these circumstances is often compounded by the financial strain they can cause. It's during these trying times that the true value of peace of mind becomes clear. - read more
Knowledgebase
Insurable Interest: A financial or other kind of interest in the insured item or person, necessary for a valid insurance contract.
No comments yet. Be the first to share your thoughts.