AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

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 woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.

However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.

In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.

The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.

While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.

"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.

"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."

The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.

"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.

For a more detailed account of the ruling, refer to the original report by AFCA.

Published:Wednesday, 4th Sep 2024
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

Insuregroup's Remarkable Growth in Truck Insurance Policies

21 Feb 2026: Paige Estritori

Insuregroup, a specialist insurance brokerage serving Australia's transport and logistics sector, has recently announced a significant milestone: processing over 10,000 insurance policies since its inception, with a 25% increase in policy volume over the past year. This growth underscores the escalating demand for comprehensive truck insurance solutions tailored to the unique needs of Australian freight operators. - read more

ICA's Strategic Plan to Combat Escalating Motor Insurance Costs

21 Feb 2026: Paige Estritori

The Insurance Council of Australia (ICA) has unveiled a comprehensive report titled 'Motor Insurance Policy Paper - A Roadmap for Reducing Rising Premiums,' addressing the significant 42% increase in comprehensive motor insurance premiums since 2019. This surge has brought the average annual premium to $1,052 in 2024, prompting the need for coordinated action to alleviate the financial burden on consumers. - read more

Heightened Road Risks During Holiday Season: Insurers Issue Warnings

21 Feb 2026: Paige Estritori

As the Australian summer school holidays coincide with peak freight activity, insurers and transport specialists are raising concerns about heightened road risks. The surge in freight traffic, coupled with increased holiday travel, amplifies the potential for road incidents, particularly involving heavy vehicles. - read more

AustralianSuper Announces Reduction in Default Income Protection Cover

20 Feb 2026: Paige Estritori

AustralianSuper, one of Australia's largest superannuation funds, has announced a significant change to its default income protection insurance. Effective from 28 February 2026, the fund will reduce the default income protection cover to $1,000 per month. This adjustment aims to align insurance coverage with members' actual income levels and prevent over-insurance, which can erode retirement savings. - read more

APRA Postpones Changes to Individual Disability Income Insurance Policy Terms

20 Feb 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has announced a suspension of the planned changes to individual disability income insurance (IDII) policy contract terms. Originally set to take effect from 1 October 2022, the implementation has been deferred for at least two years, providing insurers and policyholders additional time to adapt to the forthcoming regulations. - read more

Click for more Insurance News