Insurer Must Pay After Unfounded Fraud Allegations
Insurer Must Pay After Unfounded Fraud Allegations
1
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.
A leading insurance company has been ordered to cover a fire damage claim submitted by a policyholder who passed away from cancer two years ago, highlighting the consequences of unjust fraud accusations.
The claim was initially submitted in January 2022 for damage incurred to the man’s remote metal home in New South Wales. The insurer denied the claim on the grounds that the property was fraudulently misrepresented in terms of its status and functionality.
The policyholder, under heavy medication due to his illness, was questioned by the insurance company’s investigators. Unfortunately, he passed away roughly five months following the submission of the insurance claim. His estate's executor took over the complaint afterwards.
Recently, the Australian Financial Complaints Authority (AFCA) determined that the insurer, IAG, did not provide adequate evidence showing that the policyholder had breached his disclosure commitments. Thus, they must honour the claim.
According to AFCA, “Even if there had been a breach, the insurer has not convincingly shown that it resulted in the renewal of the policy when it would not have been otherwise. Thus, it is fair that the insurer accepts the claim.”
AFCA pointed out that IAG did not submit a declaration from its underwriters to either prove it would not have undertaken or renewed the policy. Despite cautions regarding potential adverse inferences, the insurer failed to provide necessary documentation on its underwriting practices pertaining to this case.
Originally, IAG contended that the policyholder had wrongly described the condition of his property upon policy initiation in October 2019, claiming it was watertight, structurally sound, secure, well-maintained, and inclusive of functional kitchen and bathroom facilities, and specifying its construction date as approximately 2019.
The policy contained a clause explicitly stating, “We don’t insure buildings under initial construction.”
AFCA’s investigation found that, as of the relevant policy renewal date in October 2021, the property's construction was completed, and it had been continuously occupied for over a year, meeting structural and maintenance codes.
“Each renewal constituted a new insurance contract,” the ombudsman declared.
Moreover, AFCA emphasized that the allegation of fraud, which carries grave implications, wasn’t sufficiently supported given that for a misrepresentation to amount to fraud, it must be made either knowingly or recklessly.
EVEN if I had determined that the policyholder breached the disclosure duty-which I have not-the insurer did not provide necessary proof to show it would not have entered the 2021-22 policy period without the alleged breach,” AFCA noted.
In their ruling, AFCA also highlighted the insurance contract and product disclosure statements omitted critical information regarding the duty to avoid misrepresentation, relevant disclosure duties, or consequences of any such breaches.
For more information on the ruling, it can be reviewed here.
This article has been adapted from one originally published by Insurance News Magazine.
Insuregroup, a specialist insurance brokerage serving Australia's transport and logistics sector, has recently achieved a significant milestone by processing over 10,000 insurance policies since its inception. This accomplishment includes a 25% year-on-year increase in policy count, highlighting the escalating demand for comprehensive truck insurance solutions among Australian freight operators. - read more
The Australian Competition and Consumer Commission (ACCC) has recently approved Allianz's acquisition of RAA Insurance Holdings, a decision that has sparked discussions about the future landscape of Australia's insurance industry. This approval follows closely on the heels of the ACCC's earlier endorsement of Insurance Australia Group's (IAG) acquisition of RACQ Insurance, marking a trend towards consolidation within the sector. - read more
Australia's transport and haulage sector is currently navigating a period of heightened operational risk, marked by an uptick in both the frequency and severity of motor collision claims. This trend underscores the pressing need for fleet operators to adopt proactive risk management strategies and leverage advanced insurance solutions to safeguard their operations. - read more
Envest Group, a prominent player in Australia's insurance sector, has announced the launch of TLI Underwriting, a new agency dedicated to providing specialized insurance solutions for heavy motor fleet operators. This strategic move aims to address the unique challenges faced by larger transport businesses in Australia. - read more
The Australian Securities and Investments Commission (ASIC) has commenced legal action against QBE Insurance, alleging that the insurer misled more than 500,000 customers regarding premium discounts over a five-year period. This development has significant implications for the Australian insurance industry, particularly for policyholders seeking transparency and fairness in premium calculations. - read more
When you’re young, life is all about new experiences and making plans for a promising future. While factors like travel, career, and relationships often take centre stage, one aspect often overlooked is life insurance. It might seem like something to consider later in life, but starting a policy while you're young can be a savvy financial move. - read more
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
Choosing the right life insurance policy is one of the most important decisions for Australians, especially for those who are middle-aged or older. Life insurance provides financial security for your loved ones in the event of your passing, ensuring that they are not burdened with financial hardships. - read more
Life insurance and estate planning are critical components of financial security. They ensure that your loved ones are protected financially when you are no longer around. By understanding these tools, you can take significant steps to secure your family's future. - read more
Life insurance can seem complex at first, but understanding the basics can help demystify this important financial product. At its core, life insurance is a contract between you and an insurer, where the insurer promises to pay a designated beneficiary a sum of money upon your passing, in exchange for premium payments. - read more
Start Here !
Apply now for your free Insurance assessment and price comparisons!
Knowledgebase
Elimination Period: The time period between an injury and the receipt of benefit payments from an insurer, particularly in disability insurance.
