GMP Settles “In- Eligible” Insurance Case for the Full Benefit Amount

Published 06 Dec 2017

Our client, Ms J of Coolangatta, was formerly a nurse, and she ceased work due to chronic fatigue syndrome and associated conditions.  She was, through her corporate Superannuation Fund, insured for income protection insurance. She personally claimed under the policy and was declined by the insurer. The decline was on the basis that the insurance was not in effect at the time Ms J became sick, and stopped work.  Ms J disagreed as she understood she was and has been insured for the 10 years, and has been a member of the fund for the same period of time.

Ms J contacted GMP to investigate and take her claim to Court.  We discovered that due to an error there were 2 membership created under the same Fund Manager, and each had a separate insurance policy: one commenced after our client became ill but before she stopped work; and the other ending after she started having symptoms but before she stopped work.  This presented a very complicated argument which our firm took to Court.

We argued that the two separate policies should be interpreted together because they were meant to be only one policy, if not for the error of the fund having separated the two memberships.  We argued that our client is therefore entitled to be paid as if the policy was continuing, or in the minimum that no pre-existing conditions can be applied to the later policy. At negotiations, the insurer was willing to pay 95% of the insured amount to resolve this case.  Our client is very satisfied of this outcome as the settlement will alleviate some of the financial strain she has experienced.

Insurance and superannuation claims are exceedingly technical.  Often, they turn on the date the policy was created. At Gerard Malouf & Partners our lawyers have expertise in insurance contact claims including TPD and income protection. Should you be having a dispute or otherwise want to pursue a claim, please do not hesitate to contact our lawyers at Gerard & Malouf & Partners on 1800 004 878.


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