AFCA dispute process

Life insurance and insurance in super

Retail income protection is usually a life-insurance complaint. Group cover inside super is usually a superannuation complaint — the trustee and the insurer can both be on the file, IDR is 45 days, and a determination binds both sides. AFCA applies the PDS as written: total versus partial, hours thresholds, residual formula, and pre-existing or non-disclosure grounds. Approach documents and published determinations are collected on the Library precedent pages.

Search published determinations → · Library precedent pages →

Complaints process map

AFCA’s published lifecycle. Informal methods first; determination last. Official detail: afca.org.au/what-to-expect/the-process-we-follow.

1. 1 IDR 30 / 45 days
2. 2 Lodge Portal
3. 3 Referral Often 21 days
4. 4 Case Rules + file
5. 5 Conciliate Most close here
6. 6 Assessment Written view
7. 7 Determination Binding if accepted

Seven-step process

1. 1 Complain to the firm first (IDR)

   ASIC Regulatory Guide 271 requires the insurer, trustee, or other financial firm to run an internal dispute resolution process and give a written IDR response.

   Standard complaints: 30 calendar days. Superannuation and traditional trustee complaints: 45 days. Insurance inside super can be raised with the trustee or the insurer. Keep the IDR letter — AFCA will ask for it. If the deadline passes with no response, you can still lodge.

   TIP: Use the Document Vault (start a claim workspace) to store the IDR letter, PDS, and medical correspondence before you lodge with AFCA.

   AFCA note: Mandatory first step. Complaints that have not been through IDR are usually referred back to the firm.

2. 2 Lodge with AFCA

   Online portal (preferred), phone 1800 931 678, email i nfo @ afca .org.au, or post to GPO Box 3, Melbourne VIC 3001. Free to complainants.

   Create a portal account, name the firm (and the trustee if cover sits in super), describe the product, the issues, the loss, and the remedy you want. Upload the PDS or policy, IDR correspondence, medical and occupation al evidence, and earnings. You receive a reference number.

   AFCA note: Time limits: usually two years from the IDR response, or six years from when you became (or should have become) aware of the loss — whichever comes first. Death-benefit super complaints have a much shorter window.

3. 3 Registration and referral back

   AFCA registers the complaint and usually sends it back to the firm for a last attempt.

   If IDR is unfinished, the firm gets the remaining RG 271 time (up to 30 or 45 days). If IDR is done, a typical refer-back is 21 days (financial-difficulty files can be shorter). Many complaints close here. If not, the firm must give AFCA an IDR or EDR response.

   AFCA note: Do not stop corresponding with the firm during refer-back unless AFCA tells you otherwise — but copy AFCA on anything material.

4. 4 Case management

   A case manager tests jurisdiction against the AFCA Rules , then gathers the file.

   For income protection and TPD, AFCA applies the PDS or policy as written: own occupation versus any occupation , total versus partial / residual, waiting period , offsets, and pre-existing wording. It will ask for treating notes, occupation al evidence, and the claim file. Super complaints often join the trustee and the insurer.

   AFCA note: AFCA may exclude a complaint that is outside the Rules (wrong firm, out of time, already in court, or beyond a compensation cap). You will be told why.

5. 5 Negotiation and conciliation

   I nfo rmal resolution first — most files never reach a determination.

   The case manager may put a view, host a conciliation, or shuttle a settlement. Annual Review 2024–25: 73% of complaints closed before determination were resolved by agreement or in the complainant’s favour. Life insurance files (denial of claim, delay, quantum) often settle once the duty list and residual formula are on the table.

   AFCA note: Settlement discussions are without prejudice. A deal can still be better than a capped determination — read the numbers.

6. 6 Preliminary assessment

   If i nfo rmal methods stall, AFCA may issue a written view of how the complaint should resolve.

   The assessment sets out issues, facts, and the likely outcome. Either party can accept it (and the complaint resolves) or reject it and ask for a determination. Some simple files skip this stage and go straight to an adjudicator.

   AFCA note: Rejecting a preliminary assessment is not an appeal. It is a request for an ombudsman, adjudicator, or panel to decide.

7. 7 Determination

   A binding decision under the AFCA Rules . Superannuation determinations bind both sides.

   For complaints that are not superannuation complaints, you may accept or reject the determination. If you accept it, the firm must comply (subject to the Rules’ compensation caps). There is no AFCA appeal — only a court. Superannuation determinations are binding on both parties. Published decisions (de-identified) sit on AFCA ’s search portal.

   AFCA note: Income-stream life insurance has a monthly compensation cap in Schedule A of the Rules; lump-sum financial-loss caps are indexed. Check the current schedule before you plead quantum.

FAQ highlights

When can I lodge?

After IDR, or once the RG 271 deadline has passed with no response. Then usually within two years of the IDR response, or six years of awareness of the loss — whichever comes first. Death-benefit super complaints have a much shorter statutory window.

Does it cost anything?

No. The service is free to consumers and small businesses. Firms pay AFCA membership and complaint fees.

Is there a compensation cap?

Yes, in the general jurisdiction — Schedule A of the AFCA Rules, indexed. Income-stream life insurance (monthly IP) has a monthly cap. Superannuation complaints use a different remedy framework and determinations bind both parties.

Cover is inside super — who do I complain about?

The trustee, the insurer, or both. RG 271 lets you start IDR with either. AFCA’s superannuation jurisdiction can look at insurer decisions on insured benefits paid through the fund. Name both on the form if both decided.

Is a determination binding?

Superannuation: yes, on both parties. Other complaints: binding on the firm if you accept it. If you reject it, the determination falls away and you may go to court.

Can I see previous decisions?

Yes. AFCA publishes de-identified determinations. Approach documents (including ICA s 47 pre-existing conditions and life-insurance non-disclosure) explain how issues are read. The Library precedent pages curate the IP and pre-existing holdings.