CR403 · 2024
Pre-existing condition clause — onus and look-back proof
Claim paid after the office put the insurer to proof.
Sentrix Digital · Library · AU
Ombud guidance and precedent
NFO case reports (South Africa) and AFCA approach documents plus recurring patterns from published determinations (Australia). Illustrative of how the offices read typical wording — not advice on your policy, and not a complete digest of every decision.
Process guides: NFO dispute process · AFCA dispute process. Also in the language map: Total vs partial disability · Pre-existing condition — interactive sketches live there.
South Africa · NFO
CR356 · 2014
Two-limb pre-existing exclusion — look-back and first twelve months
Insurer accepted the office’s reading and paid.
CR351 · 2014
Pre-existing exclusion — proximate cause, not every historic diagnosis
Office distinguished the pre-existing cardiac history from later cancer as the cause of death.
CR72 · 2005
Total disability — part-time capacity is not automatically ‘not total’
Insurer made an ex gratia offer of half the claim after ambiguous handling.
CR276 · 2009
Partial permanent incapacity — residual other work is not the insured occupation
Provisional ruling: 20% partial permanent incapacity benefit; insurer abided.
CR259 · 2009
Total under own occupation — employing others to do the labour
Insurer accepted total and permanent incapacity on the occupational definition.
Australia · AFCA
AFCA Approach — ICA s 47 · 2024
Section 47: awareness of a pre-existing condition, not the diagnosis label
Approach document — applied in published determinations.
AFCA Approach — life insurance non-disclosure · 2025
Non-disclosure remedies are not a substitute pre-existing clause
Approach document — ICA s 29 variation is a different tool from an exclusion.
AFCA published IP determinations · 2024–2026
Total and partial are separate benefits — AFCA applies the PDS as written
Recurring pattern across published income-protection determinations.
How the offices describe the tests
South Africa · NFO
South Africa — how pre-existing exclusions usually work
Group IP in South Africa is often a two-limb, time-limited exclusion. The insurer carries the onus. Historic labels are not the test.
Australia · AFCA
Australia — PDS exclusion, s 47 awareness, and disclosure
Three different tools: the PDS pre-existing wording, Insurance Contracts Act s 47 (awareness), and non-disclosure / misrepresentation remedies.
South Africa · NFO
South Africa — total, partial, and leftover tasks
Own-occupation total is about material duties with continuity, not a medical grade. Partial is a different benefit (or a percentage of a lump sum), not a consolation prize for a failed total claim.
Australia · AFCA
Australia — total vs partial as two PDS benefits
AFCA applies hours, important duties, and the residual formula in the PDS. Medical severity is not the scale.