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

Sure Insurance Boosts Strata Coverage to $20 Million

11 Nov 2025: Paige Estritori

In a significant move to address the longstanding issue of insurance affordability in Northern and Regional Queensland, Sure Insurance has announced an increase in its residential strata insurance coverage from $5 million to $20 million. This strategic enhancement aims to provide body corporates and lot owners with more competitive premium options and improved access to essential insurance services. - read more

CHU's 2025 Report Shows Stability in Strata Insurance Premiums Amid Climate and Regulatory Shifts

11 Nov 2025: Paige Estritori

CHU has released its 2025 State of the Strata Market report, providing a comprehensive analysis of the current state of the industry. The report offers valuable insights into premium movements, the impact of weather events, regulatory developments, and emerging risks affecting strata insurance. - read more

TelstraSuper Announces Decrease in Income Protection Insurance Premiums

08 Nov 2025: Paige Estritori

TelstraSuper, a profit-for-member superannuation fund, has announced a substantial decrease in income protection insurance premiums for its members. Effective from 1 July 2023, members can expect reductions ranging from 11.5% to 30%, following a comprehensive review of the fund's insurance pricing. - read more

Australian Income Protection Insurance Sales Experience Downturn

08 Nov 2025: Paige Estritori

Recent data from Plan For Life indicates a sharp decline in individual income protection insurance sales in Australia, with new risk income sales experiencing an 8.3% downturn in the year ending September 2024. This contrasts with previous periods of growth, highlighting shifting dynamics within the insurance market. - read more

New Port Disruption Insurance Addresses Rising Global Shipping Challenges

08 Nov 2025: Paige Estritori

In response to escalating global shipping challenges, leading broker Marsh and Lloyd's underwriter Tokio Marine Kiln have launched a pioneering business interruption insurance specifically designed for ports. This innovative product aims to mitigate the financial impact of trade disruptions caused by various factors, including geopolitical tensions and operational strikes. - read more

Click for more Insurance News