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
Insurance Dispute Settled with New Rulings 07 Nov 2024: Paige Estritori In a recent adjudication, a property owner faced a coverage denial due to damage attributed to rodents, offering a revealing insight into insurance claim disputes. When a strata property holder reported water damage from a damaged dishwasher hose, her insurance claim was thwarted by the involvement of rodents. - read more |
Financial Sectors Grapple With High Reporting of Breaches 07 Nov 2024: Paige Estritori The landscape of financial services in Australia is facing challenges as recent disclosures highlight the magnitude of self-reported compliance breaches across industries. The Australian Securities and Investments Commission (ASIC) report for the last financial year has revealed that the insurance sector reported the second-highest number of breaches. - read more |
Call for Stronger E-Scooter Insurance Regulations in NSW 07 Nov 2024: Paige Estritori The rapid increase in e-scooter usage across New South Wales has prompted renewed calls for improved insurance regulations to safeguard both riders and pedestrians. Genevieve Henderson, president of the Australian Lawyers Alliance NSW, is advocating for mandatory insurance policies that would cover private e-scooter owners and council-managed e-scooter sharing programs. - read more |
Surge in Claims for Non-Advised Disability Income Insurance 06 Nov 2024: Paige Estritori Recent analysis reveals individual non-advised disability income insurance is leading the pack with a remarkable claims paid ratio of 113%. In stark contrast, individual policies acquired through personal advice boast a much lower ratio of 68%, as outlined by the latest prudential data. - read more |
Controversial Fire Ruling: AFCA Endorses Claim Denial 06 Nov 2024: Paige Estritori A recent decision has stirred considerable attention as an Australian Financial Complaints Authority (AFCA) ruling supported RAC Insurance's denial of a fire claim amidst significant controversy and debate. - read more |
Understanding Public Liability Insurance for IT Consultants: Risks and Mitigation Public Liability Insurance acts as a shield for businesses, and for IT consultants, it's a safeguard against the unforeseen legal costs and compensation payments arising from third-party claims. As professionals who offer expert advice and services, IT consultants face unique risks that can lead to liability claims. Having public liability insurance not only provides a financial safety net but also serves as a testament to the consultant's responsibility and professionalism. - read more
|
Essential Public Liability Coverage for Gym and Fitness Center Owners Running a gym or fitness center comes with unique responsibilities, especially when it comes to providing a safe environment for clients. In this dynamic space, where individuals engage in activities that may pose risks, it is imperative for gym owners to understand the importance of public liability insurance. This type of coverage is a cornerstone for safeguarding your business against claims arising from accidental injuries or property damage to third parties. - read more
|
The Role of Public Liability Insurance in Protecting Hospitality Venues Public liability insurance serves as a critical safety net for event organizers, often seen as a robust shield safeguarding against potential financial repercussions arising from unforeseen incidents. In the dynamic atmosphere of events, where a multitude of variables come into play, this insurance plays a fundamental role in ensuring the stability and continuance of the host's operations. - read more
|
Top Mistakes to Avoid When Choosing Public Liability Coverage Public liability insurance stands as a crucial safeguard for businesses, shielding them from the financial repercussions of legal claims. These claims can arise when members of the public suffer damages or injuries in connection with a business's operations. Understanding the basics of this coverage is not just a matter of legal compliance for many businesses, but a proactive step in asset protection. - read more
|
The Business Owner's Guide to Calculating Adequate Public Liability Coverage For any business owner, navigating the waters of legal and financial protection can be daunting. Public liability insurance is a lifeboat in this respect; by understanding its basics, businesses can better shield themselves against the unpredictable tides of liability claims. As a starting point, public liability insurance is designed to protect businesses in the event that a third party suffers an injury or property damage due to the business's operations. - read more
|
A Beginner's Guide to Public Liability Insurance: Protecting Your Business Imagine you own a cozy café where people flock for their morning coffee and a slice of solace. Now picture a customer slipping on a wet floor and sustaining an injury. Incidents like this, as unfortunate as they are, can occur in any business setting and often result in legal claims that can be financially draining. This is where public liability insurance becomes a cornerstone for safeguarding your business. - read more
|
The Role of Liability Insurance in Managing Contractor and Supplier Risks Engaging with contractors and suppliers is an integral facet of many business operations, fostering growth and expansion. However, with this collaboration comes inherent risks that can impact a business financially and legally, should any unexpected incidents arise. It is here that liability insurance steps in as a cornerstone of risk management, safeguarding businesses from potential pitfalls associated with these partnerships. - read more
|
A Guide to Public Liability Insurance for Construction Businesses When embarking on a construction project, the potential for unexpected incidents and the associated liabilities cannot be ignored. Navigating through the intricate world of insurance might seem daunting, but understanding public liability insurance can save your business from financial peril. In the ever-evolving landscape of Australian construction, its significance cannot be overstated. - read more
|
Public Liability Insurance for Manufacturers: Are You Fully Covered? Public liability insurance is a cornerstone of protection for businesses, offering a shield against claims for personal injury or property damage inflicted on third parties as a result of their operations. As manufacturers open their doors to employees, suppliers, and sometimes the public, they navigate a landscape rife with potential hazards. Public liability insurance becomes not just a safety net, but an essential aspect of responsible entrepreneurship. - read more
|
Protect Your Construction Business: The Importance of Adequate Liability Coverage Operating within the construction industry involves managing an intricate web of risks and liabilities daily. Public liability insurance stands as one of the core safeguards to protect businesses from potential financial pitfalls that may arise from these risks. - read more
|