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

APRA Implements Cap on High DTI Home Loans to Address Housing Market Concerns

13 Dec 2025: Paige Estritori

The Australian Prudential Regulation Authority (APRA) has announced a significant policy change aimed at mitigating risks in the housing market. Effective February 2026, APRA will impose a cap on high debt-to-income (DTI) home loans, limiting such loans to 20% of new home lending. This measure applies to both owner-occupiers and investors, with the exception of new housing developments. - read more

CHU's 2025 State of the Strata Market Report: Key Insights for Property Owners

13 Dec 2025: Paige Estritori

CHU, Australia's leading strata insurance underwriting agency, has released its 2025 State of the Strata Market report, providing a comprehensive analysis of current industry trends and challenges. The report indicates that strata insurance premiums have experienced a modest increase of 2.8% over the past year, rising from an average of $954 to $981 per lot annually. This growth rate is notably lower than the 3. - read more

NSW Fair Trading Proposes New Powers to Ensure Strata Property Maintenance

13 Dec 2025: Paige Estritori

The New South Wales (NSW) government has introduced a new tranche of strata reforms to parliament, aiming to enhance the maintenance and safety of apartment buildings across the state. A key component of these reforms is the proposal to grant NSW Fair Trading the authority to enter any apartment building without a warrant if there are reasonable grounds to believe that the owners corporation is failing to maintain common property adequately. - read more

ACCC Halts IAG's Acquisition of RAC Insurance Over Competition Concerns

11 Dec 2025: Paige Estritori

The Australian Competition and Consumer Commission (ACCC) has recently blocked Insurance Australia Group's (IAG) proposed acquisition of RAC Insurance Pty Limited. This decision underscores the regulator's commitment to maintaining competitive dynamics within Western Australia's insurance market. - read more

Suncorp Reaches Maximum Reinsurance Retention Following Severe Storms in Queensland and NSW

11 Dec 2025: Paige Estritori

Recent supercell thunderstorms in South East Queensland and northern New South Wales have led to a surge in insurance claims, prompting Suncorp to reach its maximum reinsurance retention of $350 million. The insurer has reported over 10,000 claims related to these events, with approximately half pertaining to home damages and the other half to motor vehicles. - read more

Click for more Insurance News