Ombudsman Upholds Policyholder’s Claim Despite Fraud Allegations

A motor insurance policyholder has won a significant dispute over fraud allegations, with the industry ombudsman ruling in favour of a payout following a controversial car accident claim.

The case revolved around an incident where the claimant's wife crashed at an intersection one evening, reportedly failing to yield.

The lack of photographic evidence due to shock and subsequent involvement of towing services complicated matters.

Suncorp, the insurer, challenged the legitimacy of the claim, citing inconsistencies in the timeline regarding the husband’s arrival at the crash scene. Additionally, the absence of a police report, unreachable towing service contacts, and testimony from local residents indicating no observed accident raised suspicion. Suncorp’s investigator even found no crash evidence at the claimed location, while a forensic expert suggested the vehicle might have been stationary when hit and noted the absence of seat belt use.

The policyholder's attempts to alter the car's insurance value compounded the insurer's doubts, particularly following a failed attempt to substantially increase its sum insured. Despite these allegations, the vehicle was insured for $52,000, down from the attempted $75,000 adjustment.

However, the Australian Financial Complaints Authority (AFCA) countered with indications that the couple had few financial motives, presenting modest savings and no debts. AFCA accepted that crash site cleanup in residential areas is understandable and argued Suncorp misapplied its forensic interpretations. Though recognising inconsistencies in the couple’s story, AFCA concluded they weren't significant enough to warrant rejecting the insurance claim.

AFCA underscores the importance of fair consideration in insurance claims and stresses that discrepancies in personal testimonies during traumatic events should be weighed with care.

Moving forward, this ruling might prompt insurance companies to reassess their investigative approaches and criteria for claim rejection based on circumstantial evidence. Such cases highlight the delicate balance insurers must maintain between vigilance against fraud and the fair treatment of policyholders.

Published:Monday, 8th Sep 2025
Source: Paige Estritori

Share this news item:

Insurance News

Swiss Re Foresees Rising Premiums Amid Increasing Global Risks

10 Sep 2025: Paige Estritori

In a comprehensive analysis, Swiss Re Institute predicts that global property and casualty insurance premiums will rise in tandem with GDP over the upcoming decade. This growth is driven by amplified natural catastrophe losses, asset accumulation, and heightened economic and litigation claims inflation. The institute's report outlines the evolving insurance landscape amid increasing global risks. - read more

Insurance Council of Australia Assists NSW Flood Claimants

09 Sep 2025: Paige Estritori

In response to the devastating floods that swept across New South Wales' Mid North Coast in May, the Insurance Council of Australia (ICA) is taking proactive steps to support the affected residents. Insurers, organised by the ICA, will be meeting with flood victims in Kempsey, Taree, and Port Macquarie to provide guidance and support as they navigate their insurance claims. - read more

Ombudsman Upholds Policyholder’s Claim Despite Fraud Allegations

08 Sep 2025: Paige Estritori

A motor insurance policyholder has won a significant dispute over fraud allegations, with the industry ombudsman ruling in favour of a payout following a controversial car accident claim. The case revolved around an incident where the claimant's wife crashed at an intersection one evening, reportedly failing to yield. The lack of photographic evidence due to shock and subsequent involvement of towing services complicated matters. - read more

NM Insurance Secures Growth with Five-Year Zurich Partnership

05 Sep 2025: Paige Estritori

In a strategic move set to bolster its market position, NM Insurance has announced a five-year agreement with capacity provider Zurich, positioning itself for further growth and increased broker confidence in its success. Since its establishment two decades ago as Nautilus Marine Insurance Agency, NM Insurance has expanded its focus beyond the recreational boat market in Australia, branching into New Zealand and diversifying into the commercial marine, caravan, and motorcycle sectors. - read more

Click for more Insurance News

Business Insurance Articles

Understanding Liability Insurance: A Must-Read for Australian Small Business Owners

Liability insurance is a form of insurance designed to offer protection against claims resulting from injuries and damage to people or property. It covers legal costs and any payouts for which the insured party would be responsible if found legally liable. Intended to protect against claims resulting from injuries and damage to other people or property, liability insurance is critical for small businesses as it shields them from potentially crippling legal expenses. - read more

The Impact of Environmental Liability on Australian Business Operations

In today's ever-evolving business landscape, the significance of environmental sustainability and legal accountability is increasingly paramount. Australian enterprises, in particular, are encountering a growing need to understand and manage environmental liability. This reality not only influences corporate image but also carries substantial financial and legal ramifications. - read more

How to Assess Your Risk Exposure and Select the Right Indemnity Coverage

Professional indemnity insurance stands as a pivotal safeguard for Australian professionals navigating the intricacies of liability in their work life. This form of insurance is designed to protect professionals against legal costs and claims for damages arising from acts, omissions, or breaches of professional duty in the course of their practice. Whether it's due to an honest mistake or an unforeseen error, the ramifications of such professional oversights can be financially crippling. - read more

How to Choose the Right Public Liability Insurance for Your Business

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

Public Liability Insurance:
A very broad term for insurance covering liability exposures for individuals and business owners. It provides broad coverage, generally including all exposures for property damage and bodily injury.

This website is owned and operated by Clark Family Pty Ltd (as Trustee for the Clark Family Trust) 43 Larch Street Tallebudgera QLD 4228, A.C.N. 010281008, authorised Financial Services Representative of Unique Group Broker Services Pty Ltd, Australian Financial Services License 509434. Visit the ASIC website for additional licensing information.

IMPORTANT: We are neither authorised nor licensed to provide insurance or insurance products. We do not recommend any specific financial products and we do not offer any form of insurance or other financial advice. All product enquiries and requests for financial and/or other advice on this website are referred to third party, qualified intermediaries with whom you can deal directly. We may receive a fee or commission from these third parties in consideration for the referral. Before any action is taken to obtain a product or service referred to by this website, advice should be obtained (from either the third part to whom we refer you or from another qualified intermediary) as to the appropriateness of obtaining those products having regard to your objectives, financial situation and needs.