Disclosure matters at claim time
Steve, a 27-year old shop assistant, made an income protection claim when he suffered a back injury that put him out of work. When OnePath discovered that Steve was in breach of the duty to take reasonable care not to make a misrepresentation as he didn't disclose an extensive history of back issues when he applied for his cover in 2020, the decision was made to decline Steve's claim.
Steve's income protection claim
Steve, a 27-year old supermarket worker, with the help of his adviser applied for life cover with optional TPD cover and income protection with OnePath.
What happened...
On his application form Steve was asked, among other things, the following questions:
- Are you currently off work or unable to perform any of the duties of your usual occupation?
- Have you ever been off work for more than seven consecutive calendar days due to a medical condition?
- In the last five years have you seen a medical professional for a personal illness or injury, test, investigation?
- Please confirm whether you have ever: been diagnosed with, had symptoms of, been treated or prescribed medication for, or had or been advised to have a consultation for any of the following conditions: Any back, neck, joint or limb pain or disorder; or any type of injury that required treatment by a medical or health care professional.
- Have you made a claim or received benefits for, or do you intend making a claim for any of the following:
- Sickness, accident or disability benefits
- Workers compensation
- Veteran’s affairs benefits
- Any other form of compensation
Steve responded ‘No’ to each of these questions and was offered cover based on those responses.
A year later, Steve made a claim on his income protection due to a back injury that put him out of work.
As part of the usual claim process, OnePath obtained medical reports from his treating doctors to support his claim. These reports showed that his back condition was well known to him since 2018. In fact, Steve had both an MRI and a CT scan on his back in the month before applying for his insurance.
On further investigation, Steve’s medical records indicated an extensive history of back issues from 2018 to 2020, and Steve was actually on Centrelink and workers compensation claims at the time he made his insurance application.
Our decision
At OnePath, we’re in the business of paying claims.
In fact, we pay over 92% of all claims on advised policies. However, cases like Steve’s and others that don't meet policy definitions make up the 8% we decline.
In Steve’s case, had he disclosed his previous back injury, his adviser would have worked with OnePath to tailor a policy to provide him with income protection. It is most likely however, that Steve’s policy would have excluded cover for back issues.
Based on Steve’s decision to not be completely honest when applying for his insurance, his claim was unable to be paid.
At OnePath, we have the top-rated claims team in the country, and are proud to be there for our customers when they need us most.
Whilst the names have been changed to protect the individual claimant, this case study is based on the actual circumstances of the claimant. This is for illustrative purposes only, and claims will be assessed based on the specific circumstances of each individual case.
OneCare is issued by Zurich Australia Limited (Zurich, OnePath) ABN 92 000 010 195, AFSL 232510. OneCare Super is issued by OnePath Custodians Pty Limited (OnePath Custodians) ABN 12 008 508 496, AFSL 238346. OnePath is not a related body corporate of OnePath Custodians. We recommend that you read the OneCare Product Disclosure Statement and Policy Terms available at www.onepath.com.au or by calling 133 667 before deciding whether to acquire, or to continue to hold the product.