Inside a TPD Claim: How Superannuation Insurers Decide Whether You Can Ever Work Again?

Many Australians have disability insurance which they never actively chose themselves. Almost every super fund has life, total and permanent disability, as well as income protection cover as a default option. There are many members who find out about their cover only once they get ill or injured and become unable to continue working.

This becomes even more complicated because of the following reason: there are no more finances and all the necessary papers are scattered around, while the claim, as TPD lawyers in Sydney often note, has only one big question to answer. Is this person unlikely to return to their work anymore?

The Definition That Makes or Breaks the Claim

Just being diagnosed with something usually does not make a case for a TPD claim. Every claim is measured against the definition of the particular policy, and it may vary greatly from policy to policy.

Own occupation definition of total and permanent disability implies the inability to go back to the previous occupation because of the condition. Any occupation definition implies the same, but it also means an inability to be employed at any suitable job considering the person’s education and skills. The activities of daily living definition implies that a person cannot perform the basic tasks of self-care anymore and is more strict than both other types.

So, for instance, a carpenter who has been hurt in his back and will not be able to do his job anymore would pass an own occupation test, but may fail the any occupation test because he may retrain and do some office job.

Moneysmart states that own occupation cover is more expensive and usually is provided as a part of outside super cover. This way, most TPD policies provided through super funds use the latter or activities of daily living definition.

Where Claims Get Held Up?

• Total and permanent disability claims often take several months, and they follow a certain scheme.
• Each step may take a month or even more. Making enquiries in written form is better.

Evidence That Answers the Policy Question

Doctors have a natural tendency to describe symptoms, scans and treatment plans, but a TPD assessment needs something more targeted: a view on future work capacity. A report that just doesn’t mention employment at all leaves the insurer to make their own guesses, which isn’t ideal.

When treating specialists share their opinions on a condition after months or even years of care, their insights are super valuable because of all that they’ve seen. On the other hand, doctors appointed by the insurer who only see the person once, well, their opinions don’t automatically carry any more weight. What really matters is how well each report matches up to the policy definition and takes into account the bigger picture of the person’s medical history.

It’s also a good idea to have a steady treatment record as well. Long gaps between appointments can definitely raise questions, even if it was because of cost or access issues, and if you can note the reason for any breaks, it just keeps the history accurate and complete.

Records That You Should Request Early On

Getting all your documents in order before you lodge your claim can save you weeks of back and forth later on. Plus, a well-prepared file will show the insurer a clear and consistent story from start to finish.

Here are some key documents you should gather before you submit your claim:

To be honest, most people don’t realise how important their employment history is going to be in this type of claim. Under the policy definition, the insurer will want to know what type of work you’d be suited to, so having accurate records of past roles is really helpful.

A Decline Doesn’t Have to Mean the End

When you get a rejection letter, it’s easy to think that’s it, you’ve run out of options. But actually, a declined claim usually sets off a review process.

The first step is usually an internal review by the super fund trustee, who has to consider whether the decision was fair. If that doesn’t work out, you can lodge an eligible dispute with the Australian Financial Complaints Authority. AFCA doesn’t guarantee a different outcome, but it does look at the decision independently, and there are time limits to keep in mind at each stage, so the sooner you act, the better.

In some cases, disputes can even go to court if the amounts or the law are complex enough. A TPD lawyer can help you figure out which path is best for your evidence and the language in your policy.

The smartest first move is often overlooked but is really simple: ask for a copy of every policy document from every fund. Once you know exactly which definition is in play, you can tailor your reports and forms to match up better.