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AFCA sides with AMP in terminal illness claim dispute

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An AMP Life policyholder who disputed the insurer’s decision to deny her claim for terminal illness benefit has lost her case before the Australian Financial Complaints Authority (AFCA).

AFCA ruled the insurer made the right call to deny the claim because the claimant did not meet the policy definition of terminal illness.

The woman had lodged her claim in September 2015 after she was diagnosed with stage 2 breast cancer. However, the claim was denied two months later in November as her treating surgeon in his claim form did not provide an estimate of her life expectancy.

While the life insurance policy she held did cover for terminal illness, it stipulated that a benefit would only be paid if there was a life expectancy of six months or less.

An AFCA case manager had in June issued a recommendation in favor of the insurer, but the claimant rejected the call, pushing for a review of the dispute and full payment of the terminal illness benefit of $41,830.

“The outcome and reasons contained in the recommendation were correct and are adopted in this determination,” AFCA said in the ruling. “Although the complainant was very sick, none of the doctors says that she had a life expectancy of six months or less.

“Because the complainant is not terminally ill, the insurer does not have to pay the benefit.”

Click here for the determination.