An Unfairly Denied Claim

Background

Our client attempted to make a claim with their insurer after being diagnosed with breast cancer. Our client had also undergone surgery to remove the cancer. The insurer denied a full claim, stating that by not undergoing a full mastectomy she could not claim the full insured benefit. Her breast cancer type did not meet their definition of cancer under their PDS. They also stated that her surgery was ‘conservative’, despite its extensive nature and toll that it took on our client. 

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The opinions of the insurer contradicted a similar decision that was considered in 2018, where it was found that the same insurer was using an outdated definition of ‘radical surgery’ for breast cancer treatment. The insurance company admitted their fault, and paid out the policy following directions from the Financial Ombudsman Service. Despite this, the insurer chose to apply the restrictive definition on our client, and deny their claim. 

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The reliance on out of date medical definitions clearly was against all community standards and expectations, and was unjust for our client. Our office noticed this unfair outcome, and immediately engaged in dispute resolution procedures to amend our client’s claims decision. 

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Goals 

• To rectify the incorrect claim outcome our client received 

• To ensure they were compensated for the other costs incurred outside of the benefit amount, including stress and indirect financial loss 

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Outcome 

We engaged in internal dispute resolution with the insurer, and when our desired outcome was not achieved we escalated the matter to the Australian Financial Complaints Authority. Our office composed multiple complaints and submissions, which sought to provide our client with the benefit she was not paid, as well as additional compensation for the extreme stress, premiums our client paid and indirect financial loss that our client experienced. 

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Our office was successful in getting our client’s claim paid in full, compensation for stress and her premiums refunded. However, we go above and beyond for our clients when assisting them with their claims, and are further escalating this case in order to get the best outcome for our client, and the industry to ensure this does not happen to other clients.

 

Have you or someone you know had a claim unfairly denied? Get in contact with us to find out how we can assist you to make a claim.