Complaining to AFCA about a life insurance or super insurance claim

If your life insurer or super fund declines a claim, delays it, cancels cover or treats you unfairly, complain to it in writing first. If you are not satisfied with its response, or it does not respond in time, lodge a complaint with the Australian Financial Complaints Authority (AFCA). AFCA is free for consumers, independent, and can make decisions that bind the insurer or fund if you accept them. Generally you must complain to AFCA within two years of the insurer's or fund's final response, and within six years of becoming aware of the loss. Special time limits apply to some super complaints, such as objections to death benefit decisions.

This guide is part of the claims and complaints guide. Check AFCA's website for the current rules before lodging.

Step 1: Internal dispute resolution

Every insurer and super fund must have an internal dispute resolution (IDR) process meeting ASIC's standards (Regulatory Guide 271).

Complain in writing, by email or the online form, and keep a copy.
Say what you want: claim paid, decision reviewed, cover reinstated, interest for delay.
Timeframes: insurers generally must give a final response within 30 calendar days. Super trustees generally have 45 days, with longer timeframes for some complaints about death benefit distributions.
If the response does not resolve the complaint, it must tell you about AFCA.

For cover in super, complain to the fund. The trustee will usually involve the insurer.

Step 2: Lodge with AFCA

You can lodge online or by phone. AFCA will usually first refer the complaint back to the firm to give it a final chance, if it has not finished IDR.

Stage	What happens
Registration and referral	AFCA checks the complaint is within its rules and refers it to the firm if IDR is incomplete
Case management	AFCA works with both parties to try to resolve it, by negotiation or conciliation
Preliminary assessment	A case manager gives a view on the likely outcome
Determination	An ombudsman or panel makes a decision, if either party does not accept the assessment

If you accept a determination, it binds the firm. If you do not accept it, you can still go to court. AFCA decides based on the law, industry codes such as the Life Insurance Code of Practice, good industry practice and what is fair in the circumstances.

What AFCA can and cannot do

AFCA can, within its rules and limits:

Require an insurer to pay a claim or reassess it.
Award interest for delay.
Award compensation for some non-financial loss, within caps.
Require a fund to reconsider a decision about a death benefit or TPD.

There are monetary limits for some claims, which differ by product type, and AFCA cannot review some matters, such as insurer pricing decisions in general (it can consider whether a premium was applied correctly). Check the AFCA rules for the limits current when you lodge.

Common life insurance disputes

Dispute	What helps your case
TPD declined: insurer says you can work in another occupation	Specialist and vocational evidence addressing jobs suited to your education, training and experience; see TPD definitions
Claim declined for misrepresentation	The exact question asked, your answer, and why you took reasonable care; see the duty to take reasonable care
Income protection benefit lower than expected	Income evidence for the 12 months before the claim, offsets applied; see offsets
Cover cancelled in super	Notices sent, your contributions, any opt-in election; see the opt-in rules
Death benefit paid to the wrong person	Evidence of dependency, nominations, the trustee's reasons
Long delay	A timeline showing missed Code timeframes and lack of updates

Worked example: a TPD dispute

Illustrative: Liam, a 52-year-old bricklayer with Year 10 schooling, claims $250,000 TPD through his super fund after a shoulder and back injury. The insurer declines, saying he could work as a "storeperson or customer service officer".

IDR. Liam's complaint, with a vocational assessment report, argues those roles do not suit his education, training and experience, and that his treating surgeon says he cannot do repetitive lifting or sustained computer work. The fund responds within 45 days, maintaining the decision.
AFCA. Liam lodges with AFCA 3 months later, within the two-year limit. AFCA's case manager seeks further medical opinions.
Outcome. AFCA's preliminary assessment favours Liam because the suggested jobs are not realistically within his capacity and experience. The insurer accepts it and pays $250,000 plus interest.

This is an illustration, not a prediction. Outcomes depend on the evidence.

Tips for a strong AFCA complaint

Lodge on time. Note the date of the final response.
Keep it organised. A short timeline, the policy terms in dispute, and the evidence.
Address the definition, not just your hardship.
Respond to the insurer's evidence with your own, such as a report from your treating specialist.
Ask for help if needed. Financial counsellors, community legal centres and the free National Debt Helpline can help with financial hardship; lawyers can help with complex claims.

Frequently asked questions

Does it cost anything to complain to AFCA?

No, for consumers. Firms pay AFCA's costs.

Do I need a lawyer for AFCA?

No. Many people lodge themselves. For large or complex TPD claims, legal help can be useful; check any fee agreement carefully.

Can I go to AFCA about a super fund's death benefit decision?

Yes, within the specific time limits for death benefit objections. The fund must tell you about those timeframes when it proposes a distribution.

Sources

AFCA — how to complain, time limits and rules
ASIC — internal dispute resolution standards (RG 271)
Moneysmart — complaining about an insurer or super fund
National Debt Helpline — free financial counselling