AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case
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.
A recent ruling by the Australian Financial Complaints Authority (AFCA) has affected a woman’s critical illness claims, as her diagnosis came within mere days of her policy's eligibility period drawing to an end.
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.
The Australian Medical Association (AMA) has recently highlighted concerns regarding the substantial market power wielded by private health insurers and its potential adverse effects on patient care and healthcare costs. In a position statement released on 4 February 2026, the AMA emphasised the need for regulatory reforms to prevent insurers from exploiting their dominant positions in the healthcare sector. - read more
Recent findings from the Australian Medical Association (AMA) reveal a concerning trend in the private health insurance sector: Australians are facing higher premiums while experiencing diminishing returns on their policies. The AMA's latest Private Health Insurance Report Card, released on 5 December 2025, highlights the urgent need for reforms to address these issues. - read more
Private health insurers in Australia are facing mounting criticism for implementing significant premium increases, despite explicit warnings from the Health Minister. This development has sparked concerns about the affordability of healthcare and the practices employed by insurers to maximise profits. - read more
In August 2025, AIA Australia, a leading life, health, and wellbeing insurer, took a significant step in addressing the nation's mental health crisis by partnering with the City2Surf event in Sydney. This collaboration aimed to raise both funds and awareness for mental health, a pressing issue that has seen a notable increase in related insurance claims over recent years. - read more
In July 2025, AUSactive, Australia's peak body for the exercise and active health sector, announced a strategic partnership with Private Healthcare Australia (PHA) aimed at reforming private health insurance to include evidence-based preventive health services. This collaboration follows recent legislative changes that permit private health insurers to offer rebates for select natural therapies, marking a significant shift in the integration of preventive health into the insurance framework. - read more
Filing an insurance claim in Australia can be a daunting process, especially if you are not familiar with the necessary steps and requirements. Claiming insurance is crucial when you need financial support, whether due to a natural disaster, accident, or another unexpected event. - read more
Welcome to our comprehensive guide on securing your financial future in Australia. In a world of uncertainties, income protection insurance plays a critical role in maintaining your financial security and peace of mind. - read more
Financial security is crucial in today's unpredictable world, where unexpected events can disrupt the stability and comfort of our daily lives. For Australians, protecting one's income and lifestyle from unforeseen circumstances is a key component of personal finance. - read more
Financial protection is an essential aspect of sound financial planning. It ensures that you and your family are safeguarded against unexpected events that could lead to financial hardship. Two common types of financial protection are income protection insurance and life insurance. - read more
Income protection insurance is a financial product designed to support individuals in the event that they are unable to work due to illness or injury. This type of insurance provides a regular income, helping to replace a portion of lost earnings and meet daily living expenses. Virtually anyone earning an income, especially those with financial dependents or significant debts, should consider the peace of mind that income protection can offer. - read more
Knowledgebase
Public Liability Insurance: Insurance which provides protection against liability to third parties.
