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.
Bupa, a leading health insurer in Australia, has unveiled plans to significantly enhance mental health services by establishing a network of clinics named Mindplace. This initiative aims to open 60 clinics nationwide by 2027, aligning closely with the government's objective of operating 61 walk-in Medicare Mental Health Centres by mid-2026. - read more
In response to financial challenges faced by Cohealth, a non-profit community health service, the federal government has allocated $1.5 million to maintain its GP services in Melbourne's inner north and west. This funding ensures that clinics in Collingwood, Fitzroy, and Kensington will remain operational until 31 July 2026, providing essential care to approximately 12,500 patients who were at risk of losing access to their GPs. - read more
Patients Australia, in collaboration with La Trobe University, has released the 2025 Patient View Report, shedding light on the increasing financial burden faced by Australians seeking healthcare services. The report indicates that 62% of patients incur out-of-pocket expenses when visiting their GP, with nearly half of these individuals paying an average gap fee of $51 or more. - read more
Australian insurers are actively revising their investment portfolios in response to evolving geopolitical events and a stabilizing economic environment. A recent report by Janus Henderson Investors reveals that 47% of insurers plan to increase their investment portfolio risk in the next 12 months, with a significant focus on private markets. - read more
Public liability insurance is an essential part of any business's risk management strategy, especially for those operating in Australia. It's designed to protect businesses when they're found legally responsible for injury or damage to third parties due to their operations. But what happens when you need to make a claim? That's where understanding the claims process becomes vital. - 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
In the fast-paced world of entrepreneurship, the only constant is change, and with change comes the inherent realm of the unknown – risk. Australian entrepreneurs, much like their international counterparts, operate in dynamic environments where unpredictability is a staple. However, the unique economic, legal, and environmental aspects of Australia demand a more localized understanding of these risks. Acknowledging this unpredictability is the first step towards mitigating potential threats to one's business venture. - read more
Public liability insurance is a crucial safety net for both businesses and individuals, providing protection against the financial fallout from claims of injury or damage that your business operations might cause to third parties. This type of insurance is designed to cover legal and compensation costs, safeguarding you from unexpected financial burdens. - read more
Start Here !
Knowledgebase
Replacement Cost: The amount it would cost to replace or rebuild an insured asset with one of similar kind and quality, without depreciation.
