Steve’s back injury claim

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 Life discovered that Steve didn't disclose an extensive history of back issues when he applied for his cover, 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 Life.

What happened...

On his application form Steve was asked, among other things, the following questions:

  1. Are you currently off work or unable to perform any of the duties of your usual occupation?
  2. Have you ever been off work for more than seven consecutive calendar days due to a medical condition?
  3. In the last five years have you seen a medical professional for a personal illness or injury, test, investigation?
  4. 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.
  5. 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, Steve was asked to submit medical records to justify his claim. The documents Steve submitted showed that his back condition was well known to him since 2016. 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 2016 to 2018, and Steve was actually on Centrelink and workers compensation claims at the time he made his insurance application.

Our decision

At OnePath Life, we’re in the business of paying claims.

In fact, we pay over 93% of all claims on advised policies. However, cases like Steve’s mean we end up declining around 7%.

In Steve’s case, had he disclosed his previous back injury, his adviser would have worked with OnePath Life 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, as it would have been considered a ‘pre-existing condition’.

Based on Steve’s decision to not be completely honest when applying for his insurance, his claim was unable to be paid.

At OnePath Life, we have the top-rated claims team in the country, and are proud to be there for our customers when they need us most.

Claim Stories
Steve’s back injury claim

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 OnePath Life Limited (OnePath Life) ABN 33 009657 176, AFSL 238341. OneCare Super is issued by OnePath Custodians Pty Limited (OnePath Custodians) ABN 12 008 508 496, AFSL 238346. OnePath Life 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.