Australian Financial Complaints Authority · AFCA Approach — ICA s 47 · 2024

Section 47: awareness of a pre-existing condition, not the diagnosis label

Approach document — applied in published determinations.

What happened

Insurance Contracts Act 1984 (Cth) s 47 limits an insurer’s use of a pre-existing condition exclusion. AFCA’s worked examples include a life policy where a brain tumour was excised days after inception: there was no formal diagnosis at application, but GP review, a same-day CT, and surgery the next day meant a reasonable person would have been aware of a serious sickness.

Holding / approach — If, before the contract, the consumer was not aware of the condition and a reasonable person in those circumstances could not be expected to have been aware of it, s 47 stops the exclusion. Awareness sits between a stray symptom and a stamped diagnosis: consultations, investigations, and contemporaneous GP notes carry the weight. Later recollection that ‘it was nothing’ is often discounted. Awareness of the condition at any time before entry defeats s 47, even if the person reasonably believed they no longer had it.

What to capture on the file

Build a pre-inception window from the records, not from the claim form. s 47 is not a duty-of-disclosure fight (that is ICA s 29 / s 21 / reasonable-care not to misrepresent). Keep exclusion and non-disclosure as separate issue cards. Super automatic cover often uses a 12-month pre-existing limitation — still read the PDS, and still test awareness.

What happened

What to capture on the file

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