• AFRM

Claims Case Study:

Updated: Jul 16

Originally published on 7 May 2020



“We’ve recently reviewed the medical definitions in trauma, income protection and total and permanent disablement plans, and we have applied some of them so that your cover is up to date with advances in medical technology and treatments.”


In December 2018, Olive [name changed to protect client privacy] asked AFRM for assistance after a Trauma claim for Melanoma excision had been rejected by her insurer.

Olive had lodged a claim for trauma recovery benefit in August 2018, after being diagnosed with Malignant Melanoma - Clark level 4, back in 2011.

Olive had come to AFRM from another adviser and as such we were not involved in the lodgement of her original claim.


AFRM’s Melbourne office team investigated the case and found that the reason the claim had been rejected was that Olive had a very old Trauma policy that was established in 1993; and that the medical definitions within it had effectively not kept up with the latest medical knowledge and definitions.

A frustrated Olive wondered why she had been paying her premiums for all these years only to find the medical definitions within that policy were obsolete. AFRM contacted the insurer, on Olive’s behalf, and asked for a copy of the policy.

Curiously in December 2018, after rejecting her claim, Olive received formal correspondence from her insurer notifying her that the medical definitions within her policy were being updated.

The letter advised: 

“We’ve recently reviewed the medical definitions in trauma, income protection and total and permanent disablement plans, and we have applied some of them so that your cover is up to date with advances in medical technology and treatments.”

Armed with this information and a thorough analysis of the terms and definitions within the original policy, early in 2019 AFRM reached out to senior management at the insurer seeking a review of the previous decision.

Thanks to the respect with which AFRM is held in the industry, the insurer dedicated a claims Team Leader to the address the matter the very next day.

After further discussions between AFRM and the insurer relating to the fact that Olive’s policy definitions should have been automatically upgraded over time, by late March 2019, the insurer advised AFRM that the matter was under formal internal review.

In late April 2019, AFRM was advised that the formal review had found in favour of Olive.

It noted that:

“Upon further review and investigation, [the insurer] have obtained clarification that an upgrade to your Client’s Policy did take place in 2004.”

Olive was ecstatic to hear from AFRM that the original decision had been overturned and that she was being awarded close to $200,000.

Even better, the benefit was backdated to the original diagnosis in 2011, increasing the payout amount by almost $100,000 from what it would have been otherwise.

Through the course of clarifying details of the benefit payment, Olive was kind enough to comment to AFRM’s Associate Adviser, Sonal Brar:

“I thank you once again for being patient with me and I really do appreciate the help.”
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