Insurer Must Pay After Unfounded Fraud Allegations
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.
A leading insurance company has been ordered to cover a fire damage claim submitted by a policyholder who passed away from cancer two years ago, highlighting the consequences of unjust fraud accusations.
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.
QBE Insurance Group, a prominent player in the Australian insurance sector, has recently experienced a notable decline in its share value, reaching a seven-month low. This downturn is primarily attributed to a slowdown in the company's premium rate growth during the third quarter of the 2025 fiscal year. - read more
The Australian Competition and Consumer Commission (ACCC) has recently voiced concerns regarding Insurance Australia Group's (IAG) proposed acquisition of the Royal Automobile Club of Western Australia's (RAC) insurance business. Valued at A$1.35 billion, this deal aims to expand IAG's footprint in Western Australia. However, the ACCC warns that such consolidation could diminish competition in the state's motor and home insurance markets, potentially leading to higher premiums and reduced service quality for consumers. - read more
QBE Insurance Group, Australia's largest insurer by market value, has recently experienced a significant downturn in its share price, reaching a seven-month low. This decline is primarily attributed to a slowdown in the company's premium rate growth during the third quarter of fiscal 2025. For tradespeople across Australia, this development could have notable implications, particularly concerning insurance premiums and coverage options. - read more
The Australian Securities and Investments Commission (ASIC) has recently raised significant concerns regarding the quality of financial advice provided to individuals about self-managed superannuation funds (SMSFs). This development is particularly relevant for tradespeople considering SMSFs as a means to manage their retirement savings. - read more
Australia's financial regulators, the Australian Prudential Regulation Authority (APRA) and the Australian Securities and Investments Commission (ASIC), have issued a strong warning to the country's A$4.5 trillion superannuation industry. They emphasize the urgent need to prepare for an anticipated influx of approximately 2.5 million retirees over the next decade. This development holds significant implications for tradespeople, many of whom rely on superannuation funds for their retirement savings. - read more
For tradesmen and trade professionals, venturing into the world of business comes with its set of challenges and risks. Among the myriad of precautions to consider, one critical safeguard stands out for its ability to protect both the tradesperson and their clients: Public Liability Insurance. This form of coverage is not just a safety net; it is a cornerstone of a responsible business practice within the trade industry. - read more
As an Australian business owner, you face numerous financial risks daily. Accidents can happen at any time, whether it's a slip and fall on your premises or damage caused by your products or services. These incidents can lead to costly legal actions that may put significant strain on your business finances. - read more
Running a business comes with inherent financial risks. Whether you own a small café or a large construction company, unforeseen incidents can lead to significant financial losses. - read more
Liability insurance is a form of coverage that protects businesses against claims resulting from injuries and damage to people or property. It provides crucial peace of mind, ensuring that your business is shielded from potentially devastating financial losses due to lawsuits or claims against it. - read more
Running a small business in Australia comes with its own set of challenges and risks. One crucial aspect that should never be overlooked is insurance, particularly public liability insurance. The reason is simple: it offers essential protection against claims of property damage or personal injury caused by your business operations. - read more
Start Here !
Knowledgebase
Liability Insurance: A type of insurance that provides protection against claims resulting from injuries and damage to people and/or property.
