Insurer Prevails in Dispute Over Misrepresentation of Mental Health

4

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
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

Australian Food Super Implements Age-Based Insurance Premium Structure

03 Feb 2026: Paige Estritori

Australian Food Super has announced a transition to age-based pricing for its insurance offerings, a move that will see premium costs vary according to members' age brackets. Effective November 1, 2025, this change aims to align insurance costs more closely with the risk profiles associated with different age groups. - read more

Australian Life and Income Protection Insurance Premiums Experience Notable Decline

03 Feb 2026: Paige Estritori

Recent research from Rainmaker Information indicates a significant decrease in life and income protection insurance premiums across Australia. Direct life premiums have fallen by 7% since 2024, while direct income protection premiums have seen reductions of 12% and 13% for policies with 30-day and 90-day waiting periods, respectively. - read more

Global Insurtech Funding Sees Significant Decline Amid AI Surge

03 Feb 2026: Paige Estritori

The global insurtech sector experienced a notable downturn in funding during the fourth quarter of 2024, with total investments halving to $US688.24 million compared to the previous quarter. This decline marks the lowest annual funding level since 2018, according to data from Gallagher Re. - read more

Australian Insurance Industry Set for Significant Growth Amid Rising Natural Disasters

03 Feb 2026: Paige Estritori

The Australian general insurance industry is on a trajectory for substantial growth, with direct written premiums (DWP) projected to exceed $144 billion by 2029. This forecast, provided by data and analytics firm GlobalData, reflects a compound annual growth rate (CAGR) driven by increasing demand for coverage in response to the rising frequency of natural disasters. - read more

ASIC Calls for Urgent Improvements in Insurers' Complaints Handling Processes

03 Feb 2026: Paige Estritori

The Australian Securities and Investments Commission (ASIC) has identified significant deficiencies in the complaints handling processes of several insurers, prompting calls for immediate improvements. A recent review revealed that insurers failed to recognize one in six customer complaints, neglected to identify systemic issues, and frequently missed communication deadlines. - read more

Click for more Insurance News