AFCA Upholds Fair Evaluation in Insurance Claim Dispute
AFCA Upholds Fair Evaluation in Insurance Claim Dispute
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 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
Please Note: If this information affects you, seek advice from a licensed professional.
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
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
Ocean Underwriting, in collaboration with Tokio Marine Management Australasia, has launched a new cyber insurance product tailored for Australian small and medium enterprises (SMEs). This addition marks a significant expansion of Ocean's offerings, which already include property, liability, and professional indemnity insurance. - read more
Club Marine, Australia's leading provider of recreational boat insurance, has undertaken a comprehensive review of its product disclosure statements (PDS) to better align with contemporary boating trends and technologies. This initiative reflects the company's commitment to staying at the forefront of the marine insurance industry. - read more
When it comes to navigating the complex waters of insurance, understanding public liability insurance claims is crucial for businesses and individuals alike. Public liability insurance serves as a safeguard, protecting against the financial repercussions that arise from accidents or injuries that occur on your premises or through your operations. In this introductory section, we will delve into the essence of public liability insurance and underline its significance. - read more
Liability insurance is a type of coverage designed to protect you from claims arising out of injuries or damages to other people or property. For freelancers, who often juggle multiple projects and clients, liability insurance can offer a safety net that reduces financial risk and instability. - read more
In the ever-evolving landscape of Australian commerce, business insurance stands as a crucial bulwark, safeguarding enterprises against unforeseen financial perils. Recognizing this, our in-depth exploration begins with an overview of the monumental role business insurance plays for Australian companies, both large and small. It's a cornerstone for risk management, providing business owners with peace of mind as they navigate the intricacies of their industries. - read more
Public liability insurance is a key consideration for business owners in Australia. This type of insurance helps protect businesses against claims made by third parties for injuries or property damage. But what exactly does it do? In simple terms, public liability insurance covers legal costs and expenses, as well as any damages awarded, if your business is found liable for an incident. - read more
Start Here !
Knowledgebase
Term Life Insurance: A life insurance that provides a cover for a specific period of time - usually one to five years or until the insured reaches age 65 or 70.
