› Conditions, warranties and exceptions – exclusion clauses – continuous work-hours requirement for TPD 'Any Occupation' definition
Insurance
› Insurance Contracts Act 1984 (Cth) s 54
› Whether failure to work required hours due to unrelated injury is an 'act or omission' – insurer may not refuse to pay claim
Insurance
› Insurance Contracts Act 1984 (Cth) s 54
› Restrictions or limitations inherent in the claim – essential character of policy – temporal limitation collateral to cover
Insurance
› Life insurance
› Group life policy in superannuation fund – total and permanent disablement – eligibility status requirements
Quick Take
1For the purposes of s 54 of the Insurance Contracts Act 1984 (Cth), no distinction is drawn between provisions defining the scope of cover and conditions or exclusions; the inquiry is into the substantive effect of the contract and the insured's actual act or omission relied on to refuse the claim, subject only to restrictions or limitations inherent in the claim, identified by reference to the essential character of the policy.
2The essential character of a group life insurance policy covering death, terminal illness and total and permanent disablement is the risk of harm to an insured member while covered; a requirement that the member have been continuously working 15 hours or more per week in the three months before disablement is a temporal limitation or qualification collateral to that character, not a restriction inherent in a TPD claim, so an insured's failure to satisfy it is an 'act or omission' to which s 54 can apply.
3An insurer does not establish prejudice under s 54 merely because its liability is expanded by being precluded from relying on the insured's non-satisfaction of a condition; on the facts, where the non-compliance (absence through an unrelated temporary injury) neither caused nor contributed to the disabling injury and caused no prejudice, the insurer could not refuse the claim.
