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• AFCA Approach — ICA s 47 — Section 47: awareness of a pre-existing condition, not the diagnosis label Ombud precedent 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.
• AFCA Approach — life insurance non-disclosure — Non-disclosure remedies are not a substitute pre-existing clause Ombud precedent A s 29(6) variation must put the insurer in the position a reasonable and prudent insurer would have been in at entry. AFCA may narrow or strip a retrospective exclusion that other prudent insurers would not have applied. Declining the claim and varying the contract are two decisions; each needs its own proof. An exclusion that does not cover the claimed condition does not save a bad variation.
• AFCA published IP determinations — Total and partial are separate benefits — AFCA applies the PDS as written Ombud precedent AFCA does not grade medical severity as ‘total’ or ‘partial’. It asks which definition the person met in each month: hours actually worked, important income-producing duties, and earnings against pre-disability income. Working more than the hours threshold usually takes the file out of total and into partial — if the earnings drop and duty test are also met. Not working, but still able to do the important duties, fails total. A graded return is often residual, not recovery and not a failed total claim. Where the PDS deems a ≤10-hour week to be a 100% loss, AFCA applies that deeming.