Ombudsman Upholds Policyholder’s Claim Despite Fraud Allegations

A motor insurance policyholder has won a significant dispute over fraud allegations, with the industry ombudsman ruling in favour of a payout following a controversial car accident claim.

The case revolved around an incident where the claimant's wife crashed at an intersection one evening, reportedly failing to yield.

The lack of photographic evidence due to shock and subsequent involvement of towing services complicated matters.

Suncorp, the insurer, challenged the legitimacy of the claim, citing inconsistencies in the timeline regarding the husband’s arrival at the crash scene. Additionally, the absence of a police report, unreachable towing service contacts, and testimony from local residents indicating no observed accident raised suspicion. Suncorp’s investigator even found no crash evidence at the claimed location, while a forensic expert suggested the vehicle might have been stationary when hit and noted the absence of seat belt use.

The policyholder's attempts to alter the car's insurance value compounded the insurer's doubts, particularly following a failed attempt to substantially increase its sum insured. Despite these allegations, the vehicle was insured for $52,000, down from the attempted $75,000 adjustment.

However, the Australian Financial Complaints Authority (AFCA) countered with indications that the couple had few financial motives, presenting modest savings and no debts. AFCA accepted that crash site cleanup in residential areas is understandable and argued Suncorp misapplied its forensic interpretations. Though recognising inconsistencies in the couple’s story, AFCA concluded they weren't significant enough to warrant rejecting the insurance claim.

AFCA underscores the importance of fair consideration in insurance claims and stresses that discrepancies in personal testimonies during traumatic events should be weighed with care.

Moving forward, this ruling might prompt insurance companies to reassess their investigative approaches and criteria for claim rejection based on circumstantial evidence. Such cases highlight the delicate balance insurers must maintain between vigilance against fraud and the fair treatment of policyholders.

Published:Monday, 8th Sep 2025
Source: Paige Estritori

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Knowledgebase

Claim Adjuster:
An insurance professional who investigates and evaluates insurance claims to determine the amount the insurance company should pay.