Insurer Prevails in Dispute Over Misrepresentation of Mental Health

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 dispute arose when the complainant made a claim on her total and permanent disability (TPD) policy for major depression. In response, MLC (the insurer) decided to amend the policy by adding an exclusion for mental illness, effectively denying the claim.

The insurer argued that it was within its right to add the exclusion because the complainant had misrepresented her mental health history when applying for the policy in March 2015.

Upon reviewing the application form, it was discovered that the complainant failed to disclose her use of anti-depressant medication and provided incorrect answers to questions regarding her mental health.

Misrepresentation of Mental Health

One of the questions on the application form asked whether the complainant had ever experienced or sought advice for anxiety, stress, or sleeplessness. The complainant answered "No," despite having a history of depression and taking medication for it.

The Australian Financial Complaints Authority (AFCA) determined that this answer was a misrepresentation.

The complainant also provided a false answer to another question regarding the use of medications in the last five years. Despite her two-year history of depression and recent medication use, she answered "No" to the question.

AFCA concluded that these misrepresentations were significant in the insurer's decision to add the exclusion for mental illness.

Ruling in Favor of the Insurer

The complainant argued that she was unaware of her depression diagnosis and believed her medication was intended to improve her mood, rather than treat depression.

However, AFCA rejected her explanation, noting that she had sought treatment for "anxiety-related condition" and had taken medication to improve her mood.

AFCA ruled in favor of MLC, stating that the insurer demonstrated the intent to add a mental illness exclusion even without the complainant's misrepresentations. The ombudsman also noted that other insurers would have made similar decisions.

Published:Tuesday, 5th Dec 2023
Author: Paige Estritori

Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.

Share this news item:

Insurance News

Clear

Understanding AustralianSuper's Income Protection Reduction

16 Apr 2026: Paige Estritori

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

CareSuper Enhances Income Protection Benefits for Members

16 Apr 2026: Paige Estritori

CareSuper has announced an enhancement to its income protection insurance offerings. Starting 1 April 2026, members can apply for income protection cover up to 87% of their current income, including up to 12% super contributions. This is an increase from the previous limit of 85% of income, which included up to 10% super contributions. - read more

APRA Enhances Capital Requirements for Sovereign Insurance Australia

16 Apr 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has recently mandated an additional capital requirement of $2 million for Sovereign Insurance Australia Pty Ltd. This directive is part of APRA's ongoing efforts to bolster the financial stability and resilience of insurers operating within Australia. - read more

Europ Assistance Australia Enters Market with APRA's Approval

16 Apr 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has granted a new general insurance licence to Europ Assistance Australia, marking the company's official entry into the Australian insurance market. This development introduces additional competition and diversity within the sector. - read more

APRA Calls for Immediate Action on Extreme Weather Risks

16 Apr 2026: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has released a landmark report emphasising the urgent need for ambitious action and investment to shield communities from the escalating impacts of extreme weather events. The Insurance Climate Vulnerability Assessment (ICVA) serves as a stress test, highlighting risks that are already materialising and supporting the insurance industry's calls for immediate mitigation efforts. - read more

Click for more Insurance News