Insurer Must Pay After Unfounded Fraud Allegations
Insurer Must Pay After Unfounded Fraud Allegations
1
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.
The National Truck Accident Research Centre (NTARC) has released its 2025 Major Incident Investigation Report, shedding light on the primary human factors contributing to significant truck crashes across Australia. The findings emphasise the critical roles of inattention, distraction, and inappropriate speed in these incidents, underscoring the necessity for targeted safety interventions within the transport industry. - read more
QBE Australia Pacific has recently entered into a strategic partnership with Sure Insurance, aiming to bolster its broker-distributed householders cover. This collaboration signifies a concerted effort to provide more comprehensive and accessible home insurance solutions tailored to the diverse needs of Australian homeowners. - read more
Underwriting agency Blue Zebra has recently announced the establishment of new capacity arrangements for its home building and contents, landlord, and small to medium-sized enterprise (SME) package products. This strategic move is set to enhance the agency's ability to offer comprehensive and competitive insurance solutions tailored to the evolving needs of Australian homeowners and business operators. - read more
The Insurance Code Governance Committee has imposed a $30,000 penalty on AIG Australia for breaching its obligations related to claims handling. The insurer failed to inform customers about delays in processing their claims and neglected to advise them of their right to escalate complaints to the ombudsman. This regulatory action underscores the critical importance of transparency and communication in the insurance claims process. - read more
Insurance Australia Group (IAG), a leading insurer in Australia, has highlighted the significant impact of climate change on the cost of home insurance. The company reports that the increasing frequency and severity of weather events are contributing to rising premiums for homeowners. - read more
Life insurance is one of those cornerstones of financial planning that often gets overlooked. Yet, the importance of life insurance in safeguarding your family's future cannot be overstated. It's a robust financial instrument that provides peace of mind, knowing that your loved ones will be financially secure in the event of your untimely passing. This introductory section lays the groundwork for understanding why life insurance is pivotal in your family's financial health. - 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 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
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
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
Insurance Deductible: That part of an insurance claim that must be paid by an insured person before the the balance is paid by the insurer.
