Income Insurance Online :: News
SHARE

Share this news item!

AFCA Upholds Fair Evaluation in Insurance Claim Dispute

AFCA Upholds Fair Evaluation in Insurance Claim Dispute

AFCA Upholds Fair Evaluation in Insurance Claim Dispute?w=400
The Australian Financial Complaints Authority (AFCA) has directed MetLife to re-evaluate a policyholder’s income protection claim, focusing on justified interpretations of mental health exclusions.

In a case brought to attention, the claimant, who secured his coverage via superannuation, applied for a $9300 monthly policy intended for a two-year coverage span back in March 2020.

The claimant's struggle began in August 2019 when his general practitioner declared him medically unfit for work due to "significant psychological distress," primarily catalyzed by workplace bullying.

As a recourse, the individual took personal leave in August followed by paternity leave in October of the same year. Although he resumed work in October 2020, he had to suspend his professional engagements again by December.

In September 2021, the claimant submitted a request for income protection benefits, citing an adjustment disorder diagnosed with mixed anxiety and depression as the reason inhibiting his capacity to work.

However, MetLife rejected the claim in July 2022, accusing the claimant of inaccurately representing his medical history. The insurance provider argued that the applicant falsely stated he hadn’t been “diagnosed with or sought medical advice or treatment” for psychological issues at the time of application.

MetLife asserted that the applicant already exhibited psychological distress, hindering his work capability long-term, and had they known, the policy would not have been issued. They determined his stress related symptoms equated “to a psychological condition.”

The claimant countered, maintaining he neither identified with a history of psychological ailments during his application process, nor would a typical person in his context.

AFCA elaborated, saying although the complainant experienced "significant stress in 2019," ordinary perception does not always align stress with a psychological or clinical mental health condition. The inquiry focused on awareness of any conditions at the time, not diagnosis existence.

AFCA highlighted that the treating GP did not insist on mental health assessments commonly expected when symptoms emerge, and the sole "treatment" employed was voluntarily steering clear of the work environment, a decision lacking a formal diagnosis.

They elucidated that “Even if the answers given were not actually true (because with the benefit of hindsight the complainant was in fact suffering from a psychological or mental health condition), the panel accepted a reasonable person in the circumstances would also have reached the same belief as the complainant did.”

Following the conclusion, AFCA mandates MetLife to process and revisit the claimant’s submission and communicate the outcome to Hostplus, the coverage trustee, within a 60-day frame. The original content was reported by the Australian Financial Review.

Published:Friday, 1st Nov 2024
Source: Paige Estritori

Share this news item:

Insurance News

Insurance Dispute Settled with New Rulings Insurance Dispute Settled with New Rulings
07 Nov 2024: Paige Estritori

In a recent adjudication, a property owner faced a coverage denial due to damage attributed to rodents, offering a revealing insight into insurance claim disputes. When a strata property holder reported water damage from a damaged dishwasher hose, her insurance claim was thwarted by the involvement of rodents. - read more
Financial Sectors Grapple With High Reporting of Breaches Financial Sectors Grapple With High Reporting of Breaches
07 Nov 2024: Paige Estritori

The landscape of financial services in Australia is facing challenges as recent disclosures highlight the magnitude of self-reported compliance breaches across industries. The Australian Securities and Investments Commission (ASIC) report for the last financial year has revealed that the insurance sector reported the second-highest number of breaches. - read more
Call for Stronger E-Scooter Insurance Regulations in NSW Call for Stronger E-Scooter Insurance Regulations in NSW
07 Nov 2024: Paige Estritori

The rapid increase in e-scooter usage across New South Wales has prompted renewed calls for improved insurance regulations to safeguard both riders and pedestrians. Genevieve Henderson, president of the Australian Lawyers Alliance NSW, is advocating for mandatory insurance policies that would cover private e-scooter owners and council-managed e-scooter sharing programs. - read more
Surge in Claims for Non-Advised Disability Income Insurance Surge in Claims for Non-Advised Disability Income Insurance
06 Nov 2024: Paige Estritori

Recent analysis reveals individual non-advised disability income insurance is leading the pack with a remarkable claims paid ratio of 113%. In stark contrast, individual policies acquired through personal advice boast a much lower ratio of 68%, as outlined by the latest prudential data. - read more
Controversial Fire Ruling: AFCA Endorses Claim Denial Controversial Fire Ruling: AFCA Endorses Claim Denial
06 Nov 2024: Paige Estritori

A recent decision has stirred considerable attention as an Australian Financial Complaints Authority (AFCA) ruling supported RAC Insurance's denial of a fire claim amidst significant controversy and debate. - read more


Life Insurance Articles

Income Protection Insurance Explained: Ensure Your Livelihood in Times of Uncertainty Income Protection Insurance Explained: Ensure Your Livelihood in Times of Uncertainty
When life takes an unexpected turn, whether due to illness, injury, or other unforeseen events, the financial repercussions can be devastating. This is where income protection insurance becomes an essential component of maintaining financial stability. Income protection insurance acts as a safety net, ensuring that even in times of hardship, your financial obligations can be met, and your standard of living maintained. - read more
How to Compare Income Protection Policies When You Have a Medical History How to Compare Income Protection Policies When You Have a Medical History
In today's ever-changing world, financial security is a cornerstone of peace of mind, particularly for Australians grappling with medical histories. Income protection insurance emerges as a pivotal solution, safeguarding not only the individual’s fiscal health but the well-being of their dependents. This introduction explores the nuances of income protection insurance and its particular significance for those with pre-existing medical conditions. - read more
Income Protection Insurance: Understanding Waiting Periods and Benefit Periods Income Protection Insurance: Understanding Waiting Periods and Benefit Periods
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
Navigating Pre-existing Conditions in Income Protection Insurance Navigating Pre-existing Conditions in Income Protection Insurance
Income protection insurance is a safeguard that provides individuals with financial stability in the event they are unable to work due to illness or injury. This type of insurance typically replaces a significant percentage of the insured's income, ensuring that their financial commitments can still be met during periods when they cannot earn an income through employment. - read more
How to Compare Income Protection Insurance for Self-Employed Australians How to Compare Income Protection Insurance for Self-Employed Australians
For self-employed Australians, the financial stability provided by consistent income is the backbone of both personal and business success. Unlike traditional employees, who might have access to sick leave or employer-sponsored disability benefits, self-employed individuals are solely responsible for their financial security in the event of illness or injury. This is where income protection insurance steps in as a crucial safeguard. - read more
Income Protection Insurance: Understanding Waiting Periods and Benefit Periods Income Protection Insurance: Understanding Waiting Periods and Benefit Periods
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
How to Compare Income Protection Insurance for Self-Employed Australians How to Compare Income Protection Insurance for Self-Employed Australians
For self-employed Australians, the financial stability provided by consistent income is the backbone of both personal and business success. Unlike traditional employees, who might have access to sick leave or employer-sponsored disability benefits, self-employed individuals are solely responsible for their financial security in the event of illness or injury. This is where income protection insurance steps in as a crucial safeguard. - read more
Income Safety Net: How to Choose the Right Income Protection for Your Lifestyle Income Safety Net: How to Choose the Right Income Protection for Your Lifestyle
In the face of life's unpredictable twists and turns, few things are as disconcerting as the possibility of suddenly losing your ability to earn an income due to illness. Such events are often unexpected and can have significant financial repercussions that interrupt not only your flow of daily life but also compromise your future plans. - read more
How to Compare Income Protection Policies When You Have a Medical History How to Compare Income Protection Policies When You Have a Medical History
In today's ever-changing world, financial security is a cornerstone of peace of mind, particularly for Australians grappling with medical histories. Income protection insurance emerges as a pivotal solution, safeguarding not only the individual’s fiscal health but the well-being of their dependents. This introduction explores the nuances of income protection insurance and its particular significance for those with pre-existing medical conditions. - read more
Income Protection Insurance Explained: Ensure Your Livelihood in Times of Uncertainty Income Protection Insurance Explained: Ensure Your Livelihood in Times of Uncertainty
When life takes an unexpected turn, whether due to illness, injury, or other unforeseen events, the financial repercussions can be devastating. This is where income protection insurance becomes an essential component of maintaining financial stability. Income protection insurance acts as a safety net, ensuring that even in times of hardship, your financial obligations can be met, and your standard of living maintained. - read more


Start Here !
disability protection
Apply now for your free Insurance assessment and price comparisons!

Monthly Income Benefit:
Your Postcode:
All quotes are provided free and without obligation. We respect your privacy.

Knowledgebase
Professional indemnity:
An insurance that provides cover for liability incurred in the course of exercising a profession.