Operating Since 1983
Operating Since 1983
If your TPD (total and permanent disability) claim is rejected, it does not necessarily mean the matter is over. Depending on the insurer’s reasons, you may be able to provide further evidence, request an internal review or complaint, take an eligible dispute to AFCA, or consider other legal options.
The first step is to understand why the TPD claim was declined and how that decision relates to your TPD policy and the evidence provided. From there, you can work out whether there are grounds to dispute the decision.
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There are several reasons why a TPD insurance claim may be declined. The reason should be considered against the wording of the particular policy rather than a general definition of permanent disability.
Each TPD insurance policy has its own definition of total and permanent disability. Depending on the policy, this may involve your ability to return to your previous occupation, work in another occupation suited to your education, training or experience, or satisfy another specified test.
A claim may be rejected if the insurer believes the available evidence does not establish the applicable policy definition.
Medical evidence plays an important role in most disability insurance claims. An insurer may consider that the medical reports, records or other information provided do not sufficiently establish your condition, prognosis or its effect on your capacity for work or other requirements of the policy.
This does not necessarily mean more medical evidence will resolve the issue. Any further evidence should address the specific reason the claim was declined.
For mental health TPD claims, an insurer may decline the claim if the evidence does not clearly show how the condition affects your capacity for work under the relevant policy definition. Treatment history, symptoms over time and prognosis may all be relevant.
If the claim is rejected, the insurer’s reasons should be reviewed against the policy and the medical evidence provided.
An insurer may accept that you have a significant illness or injury but still decide that the definition of total and permanent disability has not been met.
Depending on the policy, the assessment may consider your work history, duties, qualifications, education, training and experience alongside the medical evidence.
Some declined claims involve questions about the insurance itself, including whether TPD cover was in place at the relevant time, which policy terms applied, exclusions or other conditions of cover.
The Product Disclosure Statement and other insurance documents should be reviewed carefully when the rejection relates to your TPD cover.
If your TPD claim has been rejected, avoid treating the decline letter as the final word without first understanding the decision.
Start with the insurer’s reasons for declining the claim. The rejection or decline letter may identify the policy definition relied upon, the evidence considered and the parts of the claim the insurer believes have not been established. These reasons provide the starting point for deciding what to do next.
Compare the insurance company’s decision with the wording of the TPD policy that applies to your claim. The relevant definition may depend on the type of cover you held and the policy terms applying at the relevant time. Do not assume that a general description of TPD found online is the same definition that applies to your claim.
Review the medical evidence, employment information, personal statements and other relevant documents that were submitted with your claim. This can help identify whether important evidence was missing, whether something was misunderstood or whether further information could directly address the insurer’s reasons.
Depending on the circumstances, options may include providing additional information, using the insurer or super fund’s internal complaint or review process, making an eligible complaint to AFCA or considering court proceedings. Different processes and time limits can apply, so the appropriate pathway will depend on the individual claim.
The right evidence for a rejected TPD claim depends on the policy definition and the reasons given for the insurer’s decision. Simply providing more paperwork will not necessarily change the outcome.
Further medical evidence may include updated medical reports, specialist reports or medical records addressing your diagnosis, treatment, prognosis, functional limitations or capacity for work.
For both physical injuries and mental health conditions, the key question is whether the evidence addresses the requirements of the relevant TPD policy.
Where work capacity forms part of the assessment, relevant evidence may include employment records, details of your previous duties, work history, qualifications, education and training.
Personal statements may also be relevant where they provide useful information about your work history, symptoms or day-to-day limitations.
Documents such as the applicable TPD policy or PDS, superannuation statements, insurance correspondence, the original claim material and rejection letter can help establish what cover applied and why the claim was declined.
There is no single TPD appeals process that applies to every denied claim. The available pathway depends on how the insurance is held, who made the decision and the nature of the dispute.
Insurers and regulated superannuation funds have internal dispute resolution processes for dealing with complaints.
An internal complaint or review may allow you to challenge the decision, provide new evidence or explain why you believe the insurer’s reasons do not properly reflect the policy or information available.
The Australian Financial Complaints Authority provides external, independent dispute resolution for eligible financial complaints, including certain life insurance and superannuation disputes. If a rejected TPD claim cannot be resolved internally, AFCA may be an available option depending on the circumstances and whether its jurisdictional requirements and applicable time limits are met.
Court proceedings may also be available for some rejected or disputed TPD claims. Whether legal proceedings are appropriate will depend on matters including the policy, the insurer’s decision, the evidence, the legal issues involved and the applicable time limits. Legal advice can help clarify the available options before court action is considered.
Strict time limits can apply to rejected TPD claims, but there is no single deadline that applies to every dispute.
Different time limits may apply to internal processes, AFCA complaints and court proceedings. If your TPD claim has been rejected, it is important to check the time limits applying to your circumstances rather than relying on a general deadline. Get in touch with The Personal Injury Lawyers to learn more about applicable time limits.
A TPD lawyer can review why your claim was rejected and help you understand the available options. The Personal Injury Lawyers can assist by:
For complex TPD claims, legal representation can also help keep the dispute focused on the policy requirements and the evidence relevant to the insurer’s decision.
The Personal Injury Lawyers handle TPD claims on a no win no fee basis. Our professional legal fees are only payable if your claim succeeds. Your costs agreement will explain how professional fees and any outlays are treated before you proceed. Get in touch with our TPD lawyers if your claim has been rejected and you would like help understanding your options.
Not necessarily. Depending on your circumstances, a rejected claim may first be disputed through an internal complaint or review process or, where eligible, through AFCA. Court proceedings may be an option in some cases, but they are not automatically required simply because a TPD claim has been rejected.
Yes, a rejected TPD claim involving a mental health condition may be able to be reviewed or disputed, depending on the circumstances.
The appropriate next step will depend on the insurer’s reasons, the applicable TPD policy and the available medical and other evidence. This may involve providing further evidence, making an internal complaint or review, or considering another dispute pathway.
There is no universal time limit for every rejected TPD claim. Different deadlines can apply depending on the policy, how the cover is held and whether you are pursuing an internal complaint, AFCA dispute or court proceedings.
It is important to check the time limit that applies to your particular circumstances as early as possible.
TPD insurance and income protection are different insurance benefits. TPD insurance generally provides a lump sum where the relevant definition is met, while income protection is designed to replace part of a person’s income while they are unable to work because of illness or injury.
Receiving an income protection benefit does not by itself determine whether a TPD claim should be accepted. The terms and requirements of the TPD policy still need to be considered separately.
Not sure whether you may be able to make a TPD claim? Our quick TPD claim checker can help you understand whether you may have a potential claim based on your circumstances. It takes around 30 seconds to complete, or you can contact our team if you would prefer to discuss your situation directly.
The Personal Injury Lawyers are long-term members of several professional legal organisations and are also listed across recognised legal directories, including the Australian Lawyers Alliance, Gold Coast District Law Association, Queensland Law Society, LawConnect and Doyle’s Guide.
Try our free 30 second claim checker or please contact us for a free assessment.
