AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

2

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

Significant Increase in Health Insurance Premiums Anticipated for 2026

21 Jan 2026: Paige Estritori

Health insurance premiums are set to experience a substantial increase in 2026, with projections indicating a global rise of 10.3%. This marks the third consecutive year of significant hikes, following increases of 10% in 2025 and 9.5% in 2024. These figures are highlighted in WTW's 2026 Global Medical Trends report, underscoring the persistent inflationary pressures affecting insurers and employer-sponsored health plans worldwide. - read more

Private Health Insurers Under Scrutiny for Profits Amid Rising Premiums

21 Jan 2026: Paige Estritori

Recent analyses have brought to light significant concerns regarding the profit margins of private health insurers in Australia, especially in the context of rising premiums. The Australia Institute has highlighted that major insurers are reporting substantial profits while simultaneously increasing premiums, a situation that has sparked criticism and calls for greater transparency within the industry. - read more

Health Minister Puts Private Health Insurers on Notice Over Pricing Practices

21 Jan 2026: Paige Estritori

Health Minister Mark Butler has issued a stern warning to private health insurers in Australia, cautioning them against employing underhanded tactics to increase premiums. This comes in response to findings from the Commonwealth Ombudsman, which revealed that some insurers have been closing old policies and introducing more expensive new ones, effectively circumventing regulatory limits on premium hikes. - read more

AUSactive Unveils Comprehensive Insurance Solution for Fitness Professionals

21 Jan 2026: Paige Estritori

AUSactive, Australia's leading body for the exercise and active health sector, has announced the launch of a new insurance product tailored specifically for fitness professionals. This initiative, developed in collaboration with global insurance broker Marsh, aims to provide enhanced protection while offering lower premiums compared to existing market options. - read more

Health Insurers to Include Natural Therapies in Coverage from 2026

21 Jan 2026: Paige Estritori

In a significant policy shift, Australian health insurers will begin offering rebates for a range of natural therapies, including Yoga, Pilates, Tai Chi, Shiatsu, Naturopathy, Western herbal medicine, and the Alexander Technique, starting early 2026. This change follows legislative amendments allowing these therapies to be covered under private health insurance for the treatment of health conditions or as part of health management programs. - read more

Click for more Insurance News