AFCA Upholds Fair Evaluation in Insurance Claim Dispute

2

In a case brought to attention, the claimant, who secured his coverage via superannuation, applied for a $9300 monthly policy intended for a two-year coverage span back in March 2020.

The claimant's struggle began in August 2019 when his general practitioner declared him medically unfit for work due to "significant psychological distress," primarily catalyzed by workplace bullying.

As a recourse, the individual took personal leave in August followed by paternity leave in October of the same year. Although he resumed work in October 2020, he had to suspend his professional engagements again by December.

In September 2021, the claimant submitted a request for income protection benefits, citing an adjustment disorder diagnosed with mixed anxiety and depression as the reason inhibiting his capacity to work.

However, MetLife rejected the claim in July 2022, accusing the claimant of inaccurately representing his medical history. The insurance provider argued that the applicant falsely stated he hadn’t been “diagnosed with or sought medical advice or treatment” for psychological issues at the time of application.

MetLife asserted that the applicant already exhibited psychological distress, hindering his work capability long-term, and had they known, the policy would not have been issued. They determined his stress related symptoms equated “to a psychological condition.”

The claimant countered, maintaining he neither identified with a history of psychological ailments during his application process, nor would a typical person in his context.

AFCA elaborated, saying although the complainant experienced "significant stress in 2019," ordinary perception does not always align stress with a psychological or clinical mental health condition. The inquiry focused on awareness of any conditions at the time, not diagnosis existence.

AFCA highlighted that the treating GP did not insist on mental health assessments commonly expected when symptoms emerge, and the sole "treatment" employed was voluntarily steering clear of the work environment, a decision lacking a formal diagnosis.

They elucidated that “Even if the answers given were not actually true (because with the benefit of hindsight the complainant was in fact suffering from a psychological or mental health condition), the panel accepted a reasonable person in the circumstances would also have reached the same belief as the complainant did.”

Following the conclusion, AFCA mandates MetLife to process and revisit the claimant’s submission and communicate the outcome to Hostplus, the coverage trustee, within a 60-day frame. The original content was reported by the Australian Financial Review.

Published:Friday, 1st Nov 2024
Source: Paige Estritori

Share this news item:

Insurance News

Life Insurance Takes Backseat in Cost-Cutting Measures 03 Dec 2024: Paige Estritori As Australians tighten their belts in the face of rising living costs, life insurance is rapidly being placed on the chopping block. The Council of Australian Life Insurers (CALI) reports that individuals are more likely to reduce life cover rather than home or car insurance. - read more

Call for Greater Transparency in Professional Indemnity Insurance 02 Dec 2024: Paige Estritori The Australian Financial Complaints Authority (AFCA) is advocating for enhanced transparency concerning the Professional Indemnity (PI) insurance maintained by member companies, highlighting its current lack of oversight regarding PI insurers. - read more

Senate Pushes for Transparency in Insurance Premiums 28 Nov 2024: Paige Estritori The Senate has called on the Australian Competition and Consumer Commission (ACCC) to adopt a more active role in monitoring insurance premiums. This comes as part of a broader recommendation advocating for insurers to enhance pricing transparency to assist consumers better understand their policies. - read more

Simplifying Insurance Advice: Industry and Consumers Aligned 27 Nov 2024: Paige Estritori The Insurance Council of Australia (ICA) is urging a revision of existing advice regulations to significantly improve customer interaction quality. This push comes ahead of an anticipated wave of reforms by the federal government expected to ease the delivery of simple advice within the insurance sector. - read more

Customer Wins in Insurance Dispute Over Laser Equipment 27 Nov 2024: Paige Estritori In a recent ruling, a salon owner successfully contested a claim with her insurance provider concerning a dispute over a laser machine. This case highlights significant issues around insurance policy interpretation and customer rights. - read more