Steve’s back injury claim
Article18 June 2024
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 9 out of 10 of all claims on advised policies.
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.
Zurich Australia Limited, trading as OnePath Life (ABN 92 000 010 195, AFSL 232510) (Zurich or OnePath) issues OneCare including OneCare External Master Trust and OneCare SMSF.
Brighter Super Trustee (ABN 94 085 088 484, AFSL 230511, RSE L0000178) (Trustee) is the trustee of Brighter Super (ABN 23 053 121 564, RSE R1000160) (Fund) and the issuer of OneCare Super. Zurich is the administrator and insurer for OneCare Super.
This information does not take into account your personal objectives, financial situation or needs. You should consider these factors and the appropriateness of the information to you. Consider seeking advice specific to your individual circumstances from an appropriate professional. You should also consider the relevant Product Disclosure Statement (PDS) for the product available at OneCare Policy Terms | OnePath or by calling us on 133 667 in deciding whether to acquire or continue to hold the product. Furthermore, some relevant products have been designed to meet certain objectives, financial situations and needs, which are described in its Target Market Determination available at Target Market Determinations | OnePath.
