Disclaimer – This article is general information and education only. It is not financial or legal advice. All disputes depend on their own facts, policies, and strict time limits. If your TPD, income protection, trauma, or other insurance claim has been rejected and you are considering making a complaint, seek tailored advice from a superannuation or insurance-claims lawyer.
If your TPD, income protection, trauma, or other insurance claim has been rejected, it’s easy to feel like there’s nowhere left to turn. But in Australia, you have a powerful, free option: AFCA.
AFCA — the Australian Financial Complaints Authority — is an independent body set up to resolve disputes between consumers and financial institutions, including insurers and superannuation trustees.
The best news? AFCA can overturn an insurer’s decision and order payment of benefits.
This guide explains:
- how the AFCA complaints process works,
- what evidence you’ll need,
- common pitfalls to avoid, and
- what outcomes to expect.
What is AFCA?
AFCA is Australia’s national financial dispute resolution scheme.
- Mandatory membership: All insurers and super funds must be members.
- Free for consumers: No cost to lodge or pursue a complaint.
- Independent and impartial: Assesses disputes based on evidence.
- Binding determinations: If AFCA rules in your favour, the insurer must pay.
- Optional for you: If you disagree with AFCA’s outcome, you can still go to court.
Key Terms in Plain English
| Term | Meaning | Notes |
|---|---|---|
| Complaint | The formal application you lodge with AFCA. | Can be online, by phone or in writing. |
| Conciliation | AFCA helps you and the insurer try to resolve informally. | Often by phone conference. |
| Case manager | AFCA officer who reviews evidence and manages your complaint. | Your main point of contact. |
| Determination | AFCA’s final written decision. | Binding on the insurer, optional for you. |
| Time limit | Generally 2 years from the date of insurer rejection. | Strict — missing it can bar your claim. |
When Can You Complain to AFCA?
You can lodge a complaint if:
- Your insurer or super fund has rejected or delayed your claim.
- You are unhappy with how your claim has been handled.
- You believe definitions, exclusions, or terms have been applied unfairly.
AFCA commonly deals with:
- TPD claim disputes.
- Income protection benefit disputes.
- Trauma/critical illness claim disputes.
- Superannuation death benefit disputes (who should be paid).
- Excessive delays in decision-making.
Step-by-Step: The AFCA Complaints Process
Step 1: Lodge the Complaint
- Submit online, by phone, or in writing.
- Provide insurer details, policy, rejection letter, and the outcome you seek.
Step 2: Insurer Response
- AFCA notifies the insurer and asks them to respond.
- Insurers usually have 21 days to reply.
Step 3: Case Management & Evidence
- If unresolved, AFCA appoints a case manager.
- Evidence is exchanged (medical reports, financial records, policy documents).
Step 4: Conciliation / Negotiation
- AFCA may arrange a phone conciliation conference.
- Many complaints are resolved at this stage with settlements.
Step 5: AFCA Decision (Determination)
- If still unresolved, AFCA reviews evidence and issues a written determination.
- Binding on the insurer/super fund.
- You can accept or reject — if you reject, you can still go to court.
What Evidence Do You Need?
- Medical reports – proving permanency/incapacity.
- Vocational/employment evidence – showing inability to retrain or work.
- Financial records – proving dependency (for death benefit disputes).
- Policy documents – PDS and schedules.
- Correspondence – rejection letters, insurer emails.
Case Studies
Case 1 – TPD Claim Overturned
Maria’s TPD claim was denied because her GP only wrote she was “currently unfit.” Her lawyer obtained specialist reports confirming permanency. AFCA found in Maria’s favour and ordered the insurer to pay.
Case 2 – Superannuation Death Benefit Dispute
Two of John’s children disputed his super death benefit. AFCA reviewed dependency evidence and ruled the benefit should be split equally.
Case 3 – Trauma Claim Under Narrow Definition
Lisa’s trauma claim for early-stage cancer was denied under a restrictive definition. AFCA deemed the definition unfair and ordered a partial payout.
Common Pitfalls in the AFCA Process
- Missing the 2-year time limit.
- Resubmitting the same evidence without addressing gaps.
- Failing to engage with AFCA deadlines or calls.
- Assuming AFCA is automatic – you still need to argue your case.
- Delaying legal advice until late in the process.
Fast-Track Checklist: Preparing an AFCA Complaint
| Action | Why It Matters | Evidence Needed |
|---|---|---|
| Lodge complaint quickly | Avoid missing the 2-year limit. | Rejection letter, policy details. |
| Gather stronger evidence | Overcome insurer’s reasoning. | Specialist medical reports. |
| Keep complete records | Prevents gaps or disputes. | Forms, correspondence, super statements. |
| Meet AFCA deadlines | Keeps complaint active. | Timely submissions. |
| Seek legal advice | Improves clarity and outcomes. | Lawyer’s review of evidence. |
FAQs
Is AFCA free?
Yes. AFCA is free for consumers and funded by government and industry.
Can AFCA force insurers to pay?
Yes. Determinations are binding on insurers but optional for you.
What if I lose at AFCA?
You can still pursue court action.
How long does the process take?
Simple cases: a few months. Complex super disputes: over a year.
Do I need a lawyer?
Not compulsory, but legal advice can strengthen your evidence and submissions.
Key Takeaways
- AFCA is a free, independent dispute resolution option for rejected insurance and super claims.
- Complaints must be lodged within 2 years of rejection.
- Strong, consistent medical and vocational evidence is often the key to success.
- AFCA decisions are binding on insurers, optional for consumers.
- If unsuccessful, you can still take your case to court.
The AFCA complaints process provides a crucial safeguard for Australians whose insurance or super claims are unfairly rejected. While it requires effort, many claims are overturned once AFCA reviews the evidence.
At TPD Claims Lawyers, we assist clients with AFCA complaints every day — from preparing evidence and submissions to challenging insurer definitions. If your claim has been rejected, contact us for a free, no-obligation assessment of your options.
Last updated: 3 September 2025