Three reasons TPD claims are declined

When illness or injury strikes, it can have devastating effects, including on your ability to continue working in your industry or profession.

Where a superannuation fund has taken out a group policy of total and permanent disability insurance (‘TPD’) for its members, you may be able to lodge a TPD claim and apply for a lump sum insurance benefit.

You must meet a definition of TPD contained in the insurance policy.  Usually, a requirement is that you have been unable to work for 3-6 months, and will be unlikely to work again, in either your own occupation, another occupation for which you are reasonably qualified by way of experience, education and training, or any other occupation.

But what happens if you have submitted a TPD claim, and it is declined? We explore three reasons why TPD claims are often declined.

1. The insurer alleges you are able to resume your pre-injury occupation

Sometimes TPD claims are declined because the insurer does not believe you are prevented from working in your occupation. This usually occurs when there is conflicting or inadequate medical evidence regarding the extent of the your injury or illness.

Most insurance companies, as part of the claim process, require two qualified medical practitioners to certify that you are totally and permanently disabled. For most people, this certification is done by your treating specialist and general practitioner. It is also common for insurers to request additional paperwork and information from your treating doctors.

If one or both medical practitioners do not agree that you are totally and permanently disabled, the insurer may find there is not enough evidence that you meet the TPD definition. The claim can then be declined.

2. The insurer alleges you can work in another occupation that is within your education, training or experience

A common reason why TPD claims are declined is that the insurer believes you are capable of working in another occupation The insurer will often allege this is within your education, training or experience.

This is common in situations where a person has worked in one occupation for most of their life. Although the medical evidence suggests they cannot perform that occupation anymore, they have worked in another industry in the past or possess transferrable skills.

When these types of declinations occur, it is usually because the TPD definition provides that you must be unable to work not only in your own occupation, but also in any other occupation for which you are reasonably qualified by way of education, training or experience.

Example

• John has worked as a boilermaker for almost all of his life, performing heavy manual labour work.
• John suffer a serious back injury and has been told by his treating doctors he is unable to ever work again as a boilermaker.
• John also has an interest in collecting antiques. About five years ago, he registered an ABN so he could sell some of his antique finds at a weekend market stall.
• The insurer declined John’s claim. It alleged John has business administration skills and can work as a business manager, which is within John’s education, training and experience due to his experience running a business.

3. You did not hold any insurance at the “date of disablement” under the insurance policy

Finally, TPD claims are often declined because the insurer alleges you did not have insurance coverage at the “date of disablement”.

The date of disablement is a deemed date prescribed under the insurance policy and is used to determine your applicable insurance coverage. It is usually the date on which you last physically worked, but can include when you were first diagnosed with your illness, or first sought medical treatment.

A common situation that arises is when a person holds insurance when they last worked in their pre-injury occupation, but returns to work at a later date in an alternative occupation. Sometimes, the insurance coverage at the date they last worked in their pre-injury occupation is different to when they last worked in any occupation. If insurance coverage ceased before the later date, a claim can be declined.

Example

• John has not worked as a boilermaker since 1 January 2019, the day of his back injury.
• At 1 January 2019, John had $100,000 of TPD insurance coverage.
• John participated in a six week work trial as a bus driver, organised by his workers compensation insurer. He finished this work trial on 1 July 2020.
• Between 1 January 2019 and 1 July 2020, John’s TPD insurance coverage ceased.
• The insurer declined John’s claim, alleging the date of disablement under the policy was 1 July 2020. At that date, he had no insurance coverage.

Do you need help with a TPD claim?

If you have been unable to work due to injury or illness, you should obtain legal advice. Your superannuation fund may have taken out a group policy of TPD insurance and you may be entitled to lodge a claim.

If your TPD claim has been declined, your lawyer can assist in requesting a review. Often, further medical evidence from your treating doctors, or an independent medical examination, will assist in overturning the insurer’s decision.

Turner Freeman are experienced in assisting injured people with TPD claims. Having a lawyer means you can ensure a professional is handling your claim and submitting the most relevant information to the insurance company. If you would like assistance with a TPD claim, contact our expert TPD lawyers on 13 43 63.