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.

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.

Published:Wednesday, 3rd Jul 2024
Source: Paige Estritori

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

Share this news item:

Insurance News

Clear

NSW Introduces Strata Law Reforms to Strengthen Community Governance

19 Nov 2025: Paige Estritori

On 27 October 2025, the New South Wales (NSW) Government implemented significant reforms to strata laws, aiming to enhance transparency, accountability, and financial management within strata schemes. These changes are designed to better meet the evolving needs of strata communities across the state. - read more

Strata Insurance Affordability Holds Steady Despite Rising House Insurance Costs

19 Nov 2025: Paige Estritori

In its 2025 State of the Strata Market report, CHU has revealed that strata insurance premiums have experienced a modest increase of 2.8%, rising to an average of $981 per lot in the year leading up to June 2025. This increment is notably lower than the 14% surge observed in house insurance premiums during the same period. - read more

Consumer Advocates Push for Ban on Strata Insurance Commissions in NSW

19 Nov 2025: Paige Estritori

Consumer advocacy groups, including the Australian Consumers Insurance Lobby (ACIL) and the Owners Corporation Network (OCN), are urging the New South Wales (NSW) Government to implement a ban on commissions related to strata insurance. They argue that such commissions create conflicts of interest and compromise transparency within the strata management sector. - read more

AFCA Criticises TAL for Unfair Termination of Income Protection Benefits

16 Nov 2025: Paige Estritori

The Australian Financial Complaints Authority (AFCA) has recently ruled against TAL, a prominent life insurer, for terminating a policyholder's income protection benefits without prior notice. This decision underscores the critical importance of procedural fairness in the management of insurance claims. - read more

Actuaries Institute Highlights Financial Strain of Mental Illness on Insurance Systems

16 Nov 2025: Paige Estritori

The Actuaries Institute has issued a call for immediate action to address the escalating financial strain that mental illness is placing on Australia's insurance and compensation systems. This appeal underscores the pressing need to ensure the sustainability of the nation's financial safety net in the face of increasing mental health-related claims. - read more

Click for more Insurance News