How to Lodge an AFCA Complaint Against Your Insurer in Australia

When your Australian insurer denies your claim or handles it unfairly, the Australian Financial Complaints Authority (AFCA) is your most powerful free tool. AFCA replaced the Financial Ombudsman Service (FOS), the Credit and Investments Ombudsman, and the Superannuation Complaints Tribunal in November 2018 to become Australia's single external dispute resolution (EDR) scheme for financial services. Understanding how to use it effectively can be the difference between a denied claim and a fully paid one.

Why Insurers Deny Claims That End Up at AFCA

Australian insurers deny claims across all product lines for reasons that frequently do not withstand scrutiny when examined by an independent authority. The most common bases for disputed denials include:

• Pre-existing condition characterizations that rely on the insurer's own medical assessments rather than treating physician records
• Non-disclosure allegations where the insurer claims material information was withheld, but the information would not have changed the underwriting decision
• "Not medically necessary" determinations for health and life insurance claims, particularly income protection and total permanent disability (TPD) disputes
• Delayed or inadequate claims handling that violates ASIC's Regulatory Guide 271 requirements for internal dispute resolution
• Property and weather claims where the insurer's assessor reaches conclusions contradicted by independent contractor reports

AFCA's jurisdiction is broad — it handles disputes involving home and contents, motor vehicle, travel, life, income protection, TPD, private health, and small business insurance.

How to Appeal Before Reaching AFCA

Step 1: Lodge a Formal Internal Complaint with Your Insurer

AFCA requires that you first attempt to resolve the dispute through the insurer's internal dispute resolution (IDR) process, unless the situation is urgent — financial hardship, serious health risk, or irreversible harm. Under ASIC's Regulatory Guide 271, your insurer has 30 calendar days to resolve your complaint. File your complaint in writing and retain the submission confirmation.

Step 2: Gather Your Documentation Package

Before your complaint reaches AFCA, compile your insurance policy (Product Disclosure Statement and Policy Schedule), all claim-related documents including lodgement confirmation, assessor reports, and photographs, the written denial letter from the insurer, the IDR response or evidence that 30 days have passed without resolution, and any independent expert evidence — contractor reports for property claims, specialist medical opinions for health and life claims.

Step 3: Register Your AFCA Complaint

File online at afca.org.au (the fastest method, approximately 20 minutes), by phone at 1800 931 678 (free call, Monday–Friday 9am–5pm AEST), by email at info@afca.org.au, or by post to GPO Box 3, Melbourne VIC 3001. Provide your full name, insurer name, policy number, a clear factual description of the dispute, your desired resolution, and all supporting documents.

Step 4: AFCA Case Registration and Insurer Referral

AFCA will register your case, assign a case number, and refer your complaint to the insurer within 2 business days. The insurer has an opportunity to resolve the complaint at this stage. Many complaints are resolved through this initial referral without further AFCA intervention.

Step 5: Conciliation

If the insurer does not resolve the complaint, AFCA appoints a conciliator. Approximately 70% of AFCA cases are resolved through conciliation without a formal determination. Present your evidence clearly, reference your policy language, and cite the specific insurer obligation you believe has been violated — whether under the General Insurance Code of Practice, the Life Insurance Code of Practice, or ASIC RG 271.

Step 6: Determination (If Conciliation Fails)

If conciliation does not produce agreement, an AFCA adjudicator reviews all evidence and issues a written determination under the AFCA Rules. The determination is binding on the insurer if you accept it. You are not obligated to accept — you can reject the determination and pursue legal action instead. AFCA compensation limits for 2025 are up to $1,085,000 for general and life insurance disputes; non-financial loss (distress and inconvenience) up to $5,500.

What to Include in Your Appeal and AFCA Complaint

• Insurance policy (PDS and Policy Schedule) confirming coverage terms and any exclusions cited
• Insurer's written denial letter and IDR response with specific policy provisions relied upon
• Independent expert reports — medical specialist opinions, building or engineering reports — that contradict the insurer's assessor
• Privacy Act 1988 (Australian Privacy Principle 12) request and the insurer's full claim file, including internal assessor notes and surveillance records
• Documented financial losses — the denied claim amount, consequential losses, and non-financial losses for the AFCA non-financial loss compensation head

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Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal