Dispute resolved in favor of income protection policyholder who refused to grant insurer “broader” access to medical information.
AIA insists on standard medical information release form for all claimants.
The policyholder argues that his psychiatrist’s reports have been sufficient for claim assessment and no additional medical information is necessary.
Despite offering his own authorization forms for written reports from his psychiatrist, the insurer informed the policyholder that his claim would not be assessed unless he signed the requested standard form.
In August, the policyholder lodged a complaint with the Australian Financial Complaints Authority (AFCA), and the ombudsman ruled in his favor. The ombudsman determined that the policy did not mandate him to sign the insurer’s standard authority form and that AIA’s stance was not aligned with the industry’s Code of Practice.
During the AFCA process, in November, another authorization was provided after the ombudsman questioned the insurer about its refusal to accept the complainant’s initial non-standard authorization letter.
“The insurer has not contested that the provided authority addressed its concerns and has not provided any other justification for considering the authority insufficient,” AFCA states.
According to the ombudsman’s ruling, the Code explicitly allows policyholders to authorize the insurer to request specific information from specific sources instead of providing a general authority.
The complainant has complied with this requirement, and the policy does not mandate the signing of a standard authority form, AFCA states in its ruling.
According to AFCA, the Life Insurance Code of Practice allows the complainant to provide a restricted authority and does not mandate the signing of the insurer’s standard authority form.
While AIA mentions potential assessment delays if a “further authority” is required, AFCA points out that the Code explicitly states that a policyholder can provide a limited authority, even if it may cause a delay in claim assessment.
According to AFCA, AIA has acknowledged that it does not currently require the requested information to assess the claim and is seeking access to it for potential future needs.
AFCA categorizes the insurer’s request for access to sensitive medical information as unjust and unreasonable.
AFCA emphasizes that the policyholder is not obligated to provide the requested authority for releasing the information. The insurer cannot impose such a requirement as a condition for fulfilling its policy obligations.
AFCA asserts that the policyholder has already authorized the release of all necessary information for claim assessment, and thus, the insurer must proceed with assessing the claim and providing the entitled benefits to the policyholder.
According to AFCA, if the insurer requires additional information in the future to assess the claim and seeks the complainant’s authority for obtaining it, they may request it at that time.
Additionally, AFCA has mandated the insurer to compensate the complainant with $2000 for the non-financial loss caused by the insurer’s mishandling of the claim. AFCA states that the insurer’s actions have resulted in mild stress and inconvenience for the complainant over an extended period from July 2022 until now.
Source : insurancenews.com.au