How Does the TPD Insurance Claims Process Work in NSW?

By 11 November 2020 Superannuation TPD
TPD Claims

Taking out Total and Permanent Disability (TPD) insurance is increasingly common. The possibility of a serious injury or illness preventing someone from ever working again has motivated many people to consider this type of insurance, which provides a lump sum payment if the claim is successful.

These days, many people also have TPD cover as part of their superannuation fund.

Unfortunately the claims process for TPD insurance is anything but straightforward. TPD insurance policies vary widely, including on the exact definition of TPD. Anyone making a claim needs to delve into the detail of their policy in order to give it the best chance of success.

Common problems which beset TPD claims include proving your level of disability; the length of wait times after your injury before being able to make a claim; exclusions in the policy, such as when you have a pre-existing injury; requirements about ongoing medical treatment or rehabiitation plans; demonstrating your work history, and more.

As a result the claims process when making a TPD claim can be time-consuming, stressful and take an extended period to resolve. Below we’ll offer some more detail on the most effective way to make a TPD claim, including how our specialist team can help you.

Requirements before making a TPD claim

Before agreeing to provide a lump sum payment under a TPD insurance policy, insurance companies will require extensive evidence to prove the extent of your disability and that you have met the other conditions under the policy. This process is why some TPD claims can be challenging and lengthy.

Making a TPD claim begins with establishing eligibility under the precise terms of the policy. This will usually involve meeting some of the requirements detailed below.

Level of disability: Is your disability as a result of injury and/or illness total and permanent so as that you are unlikely to be able to return to any type of work, or to be able to return to your previous role? TPD policies (and the premiums you pay for them) are generally divided into those that cover you for your ‘own’ occupation (i.e. whether you can return to work in your previous role), while others cover ‘any’ occupation (i.e. whether you can work in a different job or industry).

Wait times: Some policies will require the insured person to wait up to three months or longer before they can make a claim, in order to see whether the injury stabilises and its full extent can be determined.

Work history: Some TPD policies will require that the claimant was working full-time in the year before the accident or incident which caused their disability. Others will also require you be in full-time employment when the claim is made, or were working a set number of hours before the claim is made.

Loss of function: Some TPD policies may require proof that you have lost the capacity to perform several basic living tasks, such as washing yourself or going to the bathroom, before allowing a claim.

Ongoing care: The policy may require that you are complying with the need for ongoing medical care and have undergone, or are undergoing, rehabilitation for the injury.

The claims process

If you meet the eligibility requirements it’s time to contact the insurer or your super fund – if that’s how your TPD policy is held – to inform them of your intention to make a claim and find out what evidence will required to support it.

At this stage they may appoint a case manager to walk you through the process of submitting a claim. The guidance of an experienced legal practitioner can be vital at this stage. You can then submit your claim along with supporting documentation – medical reports, work information and any other relevant evidence.

It should be noted that a claimant has a duty to disclose all relevant information to the insurance company when making a claim. This is a legal requirement that will affect your claim if it is breached.

The assessment process then begins. The insurer will decide on your eligibility to make a claim and may require further information from you in support of the claim, including additional medical examinations.

The insurer then makes a decision to accept, defer or decline your claim. Deferment may mean further information is required, which you are able to provide in response. You may also be able to provide additional information in support of your claim if it is initially rejected.

If your claim is rejected, you can also appeal the insurer’s decision. Initially this appeal should be directed to the insurer, who will have an internal dispute resolution process. Insurers have 45 days and super funds have 90 days to provide a response on any appeal, though they should remain in communication with the claimant throughout that period.

If the claim is again rejected, you may lodge a complaint with the Australian Financial Complaints Authority (AFCA) or investigate the possibility of taking legal action to have the decision overturned. A complaint to the Authority must be made within two years of the insurance company’s decision to deny your claim, while legal proceedings must commence within six years of the decision.

How we can help

While some TPD claims can be quite straightforward and resolved in a few months, when an insurer challenges your eligibility under the terms of the policy, it can take much longer.

Engaging specialists in making TPD claims such as Gajic Lawyers can remove much of the stress for you as the claimant. We have wide experience in this complicated area of the law, in particular regarding superannuation TPD policies. A successful claim very much depends on the strength of your supporting evidence and we can make sure you make the strongest claim possible based on your circumstances.

For more information about any of the issues raised in this article, or to arrange an initial appointment, call us today on 1800 413 755.

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