Exploring AFCA’s Dispute Resolution Process

Introduction

The Australian Financial Complaints Authority (AFCA) ? AFCA jurisdiction Ombud scope

Retail life/IP sits in the general jurisdiction. Group cover inside super is usually a superannuation complaint — trustee and insurer can both be on the file, and a determination binds both sides.

AFCA process guide →

For disability , TPD, and income protection the practical route is always the same shape: internal dispute resolution ? Internal dispute resolution (IDR) ASIC RG 271

Complain to the firm in writing first. Standard files: 30 days. Superannuation: 45 days. AFCA will usually refer the complaint back if IDR has not finished.

AFCA process guide →

The companion process guide has the seven steps, product-line panels, history, and Annual Review stats. This article is the practice note for an income-protection or TPD file.

Two complaint families

Retail life and income protection: complain about the life company. AFCA applies the PDS as written — own occupation ? Own occupation Policy test

Usually applies in the Initial Period: unable to perform the material and substantial duties of your own occupation — not a generic job title.

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Insurance in super ? Insurance in super AFCA super jurisdiction

You may start IDR with the trustee or the insurer. Name both on the AFCA form if both decided. Death-benefit complaints have a much shorter time limit than ordinary claim disputes.

AFCA process guide →

Step-by-step

1. IDR — written complaint to the firm; keep the response. 2. Lodge on the AFCA portal (or phone, email, post). 3. Registration and referral back, often 21 days if IDR is already done. 4. Case management: Rules check and the claim file. 5. Negotiation / conciliation — most files close here (73% of 2024–25 closures before determination were by agreement or in the complainant’s favour). 6. Preliminary assessment . 7. Determination.

Time limits for most complaints: two years from the IDR response, or six years from when you became (or should have become) aware of the loss — whichever comes first. If the RG 271 deadline expires with silence, you can lodge anyway.

How AFCA reads an income-protection file

AFCA does not grade medical severity as ‘total’ or ‘partial’. It asks which PDS definition you met in each month: hours actually worked, important income-producing duties, and earnings against pre- disability income. Working more than a 10-hour threshold usually moves the file from total to partial. A graded return is often residual, not proof you were never disabled.

Pre-existing fights split three ways: the PDS definition, Insurance Contracts Act s 47 (awareness — not the diagnosis stamp), and non-disclosure / misrepresentation remedies under s 29. Do not let a decline letter collapse those into one paragraph. Approach documents and published determinations are collected on the Library precedent pages.

Practical tips

• Finish IDR in writing and diary the RG 271 clock (30 days, or 45 in super).
• Name the trustee and the insurer if cover sits in super.
• Upload the PDS, IDR letter, duty list, payslips for the residual formula, and contemporaneous medical notes.
• Map each decline ground to a clause — total vs partial, pre-existing, non-disclosure, delay — as separate issue cards.
• Check Schedule A caps before you plead a monthly IP quantum.
• Respond to AFCA i nfo rmation requests inside the 7–21 day windows. Silence delays the file, not the firm.

Closing

AFCA is i nfo rmal, free, and — for superannuation — capable of a binding outcome. It is not a court and it will not rewrite a clear PDS. A file that already maps duties to wording, splits pre-existing from disclosure, and keeps IDR correspondence in one place is the file a case manager can actually decide.

Lodge at afca .org.au/make-a-complaint, or call 1800 931 678. The full process guide on this Library has the seven steps, history, and current Annual Review figures.