Making Insurance Claims After a Diagnosis in Australia

Many Australians have insurance cover they've forgotten about or didn't know they had. After a serious diagnosis, checking every policy you might hold — including default cover inside your superannuation — is one of the most important things you can do. This guide explains what to look for, how to claim, and what recourse you have if a claim is declined. If you'd rather have a plan built around your situation, answer a few questions and we'll build one around you →

Types of policy to check

Several types of insurance policy may pay out after a serious diagnosis. The key is to check for each type — including cover you may not have actively purchased.

• Life insurance — pays a lump sum to your beneficiaries if you die. Not a direct benefit while alive, but worth confirming you have it and that your beneficiaries are correctly nominated, particularly inside superannuation.
• Trauma or critical illness cover — pays a lump sum on diagnosis of a listed condition such as cancer, heart attack, coronary artery bypass surgery, or stroke. The trigger is diagnosis, not inability to work — this can pay out even if you continue working.
• Total and permanent disability (TPD) — pays a lump sum if your condition permanently prevents you from working. Policies differ between "own occupation" (unable to work in your specific job) and "any occupation" (unable to work in any job you're suited to by training or experience). Own occupation definitions are more generous.
• Income protection — replaces a percentage of your income while illness or injury prevents you from working. Check the waiting period before payments begin, the benefit period (how long payments last), and the definition of disability used in your policy.
• Mortgage protection — meets your home loan repayments if you're unable to work. Check whether it covers illness, injury, or both, and what the waiting period is.

Default insurance inside superannuation deserves separate attention. Most Australians have life insurance and TPD cover provided automatically as a default benefit by their super fund — and many are unaware they have it. Some funds also provide income protection (often called "salary continuance insurance") as a default benefit. This cover requires no separate application and may have been in place for years. Log in to your super fund's member portal, check your most recent annual statement, or read your fund's Product Disclosure Statement (PDS) to confirm what cover you hold and at what level. Contact your fund's insurance team directly to understand how to make a claim.

Finding policies you may have forgotten

Cover from previous employers, earlier super funds, or old standalone policies is easily lost track of. Here is where to look:

• Old payslips and bank statements — look for premium deductions or super fund contributions. The fund name on older payslips may lead to a fund that held default insurance at the time.
• ATO myGov — lost super — log in to myGov and check the ATO's "Manage my super" section. This shows all super accounts held in your name, including accounts you may have lost track of. Each fund may hold associated insurance cover; contact each fund individually to ask.
• Mortgage or loan documents — some lenders attach mortgage protection or life insurance at settlement. Check your original loan documents or contact your lender to ask whether a policy was arranged alongside your mortgage.
• Employer HR records — some employers arrange group insurance schemes that cover employees automatically. Contact your current or former employer's HR team to ask whether any group life, TPD, or income protection policy covered you.
• Previous financial advisers or brokers — if you've used a financial adviser or insurance broker in the past, they may have records of policies arranged on your behalf.

Do not cancel any policy you find while investigating — even if you're unsure whether it's relevant. Check first, then decide.

Trauma and critical illness — how triggers work

Trauma and critical illness policies are more specific than they appear. Simply having a diagnosis of a listed condition is not always enough — the diagnosis must match the policy's own definition of that condition, which may be more precise than a clinical diagnosis.

For example, a policy may cover "cancer" only if it meets the policy's criteria for malignancy — certain early-stage or non-invasive cancers may be excluded or attract a reduced benefit. Heart attack definitions often require specific diagnostic evidence such as elevated cardiac enzymes or new ECG changes of a particular type. Each insurer words their definitions differently.

To give a claim the best chance of success:

• Read the relevant definition in your policy's PDS before notifying the insurer — understand exactly what the criteria are.
• Ask your specialist to provide a written diagnosis that explicitly references the clinical criteria used — relevant test results, staging, and diagnostic codes. A vague letter stating a condition name alone may not be sufficient.
• Notify the insurer promptly — most policies require notification within a specified period of diagnosis.

If your diagnosis sits close to a policy definition boundary, getting independent legal or financial advice before lodging a claim can help you frame the application correctly.

How to make a claim

The process is broadly similar across policy types, with some variation depending on whether the policy is held inside or outside superannuation.

• Notify the insurer or super fund promptly. Most policies have a notification requirement — contact them as soon as you decide to claim, even before you have all the documents together. This sets the clock and preserves your position.
• Request a claim form. The insurer will send you (or make available online) a claim form and a list of required documentation.
• Obtain a written diagnosis from your specialist. This should reference the diagnostic criteria, test results, and clinical findings relevant to the policy definition. Your GP alone may not be sufficient for some claim types.
• Gather supporting documents. These typically include: the claim form, medical reports and test results, your policy document or certificate of insurance, and proof of income (for income protection claims).
• Submit the claim. Keep copies of everything you send. Note the date of submission and obtain confirmation of receipt.

The insurer may appoint an assessor or use an in-house claims team to evaluate the claim. They may request access to your medical records (you will be asked to sign an authority), and may request an independent medical examination (IME) by a doctor of their choosing. You are generally required to attend if asked — declining can result in the claim being suspended.

What insurers can and cannot do

Insurers have legitimate rights to investigate claims, but their conduct is regulated. Under the Insurance Contracts Act 1984 and the ABA's Life Insurance Code of Practice (applicable to most life insurers), insurers are required to handle claims fairly and efficiently.

Insurers can: request your medical records (with your authority); request an independent medical examination; ask for additional information; apply policy exclusions and definitions.

Insurers cannot: unreasonably delay assessing a claim; request unnecessary information; use information in ways that breach the Privacy Act 1988.

The Australian Prudential Regulation Authority (APRA) oversees the financial soundness of insurers. The Australian Securities and Investments Commission (ASIC) regulates insurer conduct and can take action where insurers breach their obligations. If you believe an insurer is acting improperly, ASIC accepts complaints at asic.gov.au.

Claims through your super fund

When insurance is held inside superannuation, the claim process runs through the fund's trustee rather than directly with the insurer. In practice this means:

• You submit the claim to your super fund, not to the insurer directly — the trustee acts as the intermediary.
• The fund's trustee must decide whether to accept or decline the claim, after the insurer assesses it. Both the insurer's assessment and the trustee's decision can be challenged separately.
• If a TPD or income protection claim is paid inside super, the funds go into your super account first — you then need to meet a condition of release to access them (such as permanent incapacity or reaching preservation age).

Super fund trustees have their own internal dispute resolution process and are also covered by AFCA (see below). If you are unhappy with your fund's decision, you follow the same dispute pathway as for standalone policies.

If a claim is declined

A declined claim is not necessarily final. You have a clear escalation path.

Step 1 — Internal dispute resolution (IDR). Before going elsewhere, you must first use the insurer's or fund's internal complaints process. Request a formal review in writing, setting out clearly why you believe the decision was wrong. The insurer must respond within the timeframes set by ASIC's RG 271 — generally 30 calendar days for most complaints (or 45 days for superannuation complaints). Ask for all documents they relied on in making their decision.

Step 2 — Australian Financial Complaints Authority (AFCA). If the internal review doesn't resolve your complaint, you can lodge a complaint with AFCA — a free, independent external dispute resolution service. AFCA handles disputes about life insurance (including TPD and trauma), income protection, and superannuation. AFCA can award binding determinations against insurers and super funds.

Contact AFCA at afca.org.au or call 1800 931 678. There are time limits for lodging with AFCA — generally two years from when the insurer's IDR response is received, but check the current rules when you receive the IDR outcome.

For complex declined claims, particularly those involving large sums or disputed medical evidence, engaging a lawyer who specialises in insurance disputes may be worthwhile. Some operate on a no-win no-fee basis for insurance matters.

Work-related injuries — no ACC equivalent in Australia

Australia has no national equivalent to New Zealand's Accident Compensation Corporation. If your condition is work-related — caused or significantly contributed to by your work — you may have a claim under your state or territory's workers compensation scheme rather than (or in addition to) your personal insurance.

Workers compensation in Australia is state-based: each state and territory has its own scheme and legislation. Safe Work Australia coordinates national policy but claims are managed through state authorities (such as WorkCover Queensland, icare in NSW, WorkSafe Victoria, ReturnToWork SA, and so on). If your diagnosis is linked to workplace exposure or a workplace incident, contact your state workers compensation authority to understand your options.

For illness and injury that is not work-related, personal insurance — whether held inside or outside superannuation — is the primary financial protection mechanism.

Getting help with a claim

Insurance policy wording is technical and definitions are interpreted strictly. If you are unsure whether your diagnosis meets a policy definition, or if you're dealing with a complex claim or a declined claim, consider getting professional help.

• A financial adviser or insurance broker who specialises in personal insurance can help you interpret policy wording, prepare a claim, and correspond with the insurer. Many offer a free initial consultation. Check that the adviser holds an Australian Financial Services Licence (AFSL) or is an authorised representative of a licensee.
• Financial Counselling Australia — findacounsellor.financialcounsellingaustralia.org.au — free financial counsellors can provide general guidance and referrals.
• Community legal centres — some have specialist insurance or superannuation units; find your nearest at communitylegalcentres.org.au.
• National Debt Helpline — 1800 007 007 — can point you to free specialist help if insurance issues are contributing to financial difficulty.