Life Insurance Australia :: 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

Insurers Face Intense Scrutiny Over Quake Claim Rejections Insurers Face Intense Scrutiny Over Quake Claim Rejections
21 Nov 2024: Paige Estritori

In recent months, Muswellbrook, a town in New South Wales, has experienced a series of earthquakes that have left residents grappling with both physical destruction and emotional distress. Criticism is mounting against insurers as more than 600 claims have emerged, following these seismic events, yet many remain unresolved or denied. - read more
AI Regulations: A Web of Complications AI Regulations: A Web of Complications
20 Nov 2024: Paige Estritori

The Insurance Council of Australia (ICA) has raised concerns about the potential fallout from a fragmented regulatory approach to artificial intelligence and automated decision-making in the industry. There is fear that this patchwork of reforms could result in conflicting requirements, heavier compliance burdens, and increased industry confusion. - read more
APRA Survey Reveals Impact of Climate Change on Insurance Industry Practices APRA Survey Reveals Impact of Climate Change on Insurance Industry Practices
19 Nov 2024: Paige Estritori

A recent analysis by the Australian Prudential Regulation Authority (APRA) reveals that over 90% of general insurers and reinsurers anticipate climate change will influence their underwriting procedures, posing new challenges to the industry. - read more
Fraudulent Claims Lead to Complete Denial of Compensation Fraudulent Claims Lead to Complete Denial of Compensation
18 Nov 2024: Paige Estritori

In a remarkable case highlighting the severe consequences of insurance fraud, an individual's attempt to inflate a theft insurance claim has resulted in the total denial of compensation. Despite a significant portion of the claim being genuine, fraudulent actions negated any potential payout. - read more
Soaring Insurance Premiums Amid Changing Climate Soaring Insurance Premiums Amid Changing Climate
14 Nov 2024: Paige Estritori

As climate change persists, the impact of severe weather on insurance premiums is becoming more evident, pushing affordability out of reach for many Australians. Bernadette Systa, a mother of five, faced an undeniable financial strain as her annual home and contents insurance costs surged from a modest amount to more than twice what she initially paid. This experience echoes a growing dilemma faced by households across the country. - read more


Life Insurance Articles

Trauma Cover: Calculating Adequate Protection for Life's Unexpected Moments Trauma Cover: Calculating Adequate Protection for Life's Unexpected Moments
The financial fabric of our lives consists of both planning and safeguarding against the unforeseen. Trauma cover, a lesser-known but crucial aspect of personal insurance, provides this protection by offering a lump sum payment upon diagnosis of specific serious illnesses or injuries. In the tapestry of financial planning, it acts as a vital safety net, ensuring that unexpected health crises do not lead to monetary distress. - read more
Life After You: Planning Ahead With Quality Life Insurance for Your Family Life After You: Planning Ahead With Quality Life Insurance for Your Family
Life insurance is a fundamental component of a robust financial plan, yet its significance is often underestimated. It serves as a safety net, ensuring that your loved ones are financially secure in the event of your absence. Understanding life insurance is the first step towards safeguarding your family’s future. - read more
The Savvy Consumer’s Guide to Purchasing Life Insurance in Australia The Savvy Consumer’s Guide to Purchasing Life Insurance in Australia
As the landscape of finance and personal security evolves in Australia, the importance of being insured has never been more prominent. In a world of changing family dynamics, economic pressures, and higher living costs, life insurance stands as a bastion of support ensuring the well-being of loved ones in the event of unforeseen circumstances. - read more
The Impact of Parenthood on Your Life Insurance Choices The Impact of Parenthood on Your Life Insurance Choices
Life insurance, a contract between an insurer and a policyholder, is designed to provide financial protection to loved ones in the event of the policyholder's death. For parents, this protection takes on a new level of significance. The birth of a child heralds a profound shift in priorities, with a focus on safeguarding the future of one's family. Hence, understanding life insurance options becomes a crucial aspect of responsible parenting. - read more
Maximize Your Safety Net: Top Tips for Optimizing Income Protection Benefits Maximize Your Safety Net: Top Tips for Optimizing Income Protection Benefits
Welcome to a pivotal guide dedicated to empowering you with the essentials of income protection insurance in Australia. As we navigate through times of uncertainty, safeguarding your financial wellbeing becomes not just a priority, but a necessity. Income protection insurance stands as one of the key pillars of financial security, ensuring a steady flow of income during periods when you're unable to work due to illness or injury. - read more
A Millennial's Guide to Life Insurance A Millennial's Guide to Life Insurance
For many millennials, navigating the complexities of personal finance and future planning can feel like a bewildering journey. Among these financial responsibilities, life insurance emerges as a paramount consideration. More than just a safety net, life insurance can be the cornerstone of a sound financial strategy, providing peace of mind for both the policyholder and their loved ones. - read more
The Savvy Consumer’s Guide to Purchasing Life Insurance in Australia The Savvy Consumer’s Guide to Purchasing Life Insurance in Australia
As the landscape of finance and personal security evolves in Australia, the importance of being insured has never been more prominent. In a world of changing family dynamics, economic pressures, and higher living costs, life insurance stands as a bastion of support ensuring the well-being of loved ones in the event of unforeseen circumstances. - read more
The Digital Age of Insurance: Keeping Costs Down with Online Quotes The Digital Age of Insurance: Keeping Costs Down with Online Quotes
The horizon of the insurance industry has undergone a transformative shift with the advent of digital technology. With a few clicks, consumers can navigate the once-complex world of insurance policies from the comfort of their home. The digital landscape for insurance services offers unprecedented access to information, comparisons, and instant communication, fostering a more empowered insurance client. - read more
How Life Insurance Provides Financial Security for Your Loved Ones How Life Insurance Provides Financial Security for Your Loved Ones
Life insurance is a crucial part of any comprehensive financial plan, providing peace of mind that your loved ones will be financially secure in the event of your passing. - read more
Understanding Life Insurance: How to Determine Coverage Amounts Understanding Life Insurance: How to Determine Coverage Amounts
Life insurance is a cornerstone of financial planning, offering peace of mind to you and security for your loved ones. It's a contract between you and an insurance company: in exchange for regular premiums, the insurer agrees to pay a sum of money to designated beneficiaries upon your passing. This vital tool ensures that your family's financial needs can be met during an incredibly difficult time. - read more


Start Here !
life insurance
Apply now for your free Insurance assessment and price comparisons!

Life Cover Amount:
Your Postcode:
All quotes are provided free and without obligation. We respect your privacy.

Knowledgebase
Rider:
An optional provision added to an insurance policy that provides additional benefits or coverage.