People often worry when they need to make a TPD insurance claim (or any insurance claim for that matter) that the insurer will find a loop-hole or trick them into making a mistake in the claims process so that they can reject your claim. You are right to be concerned. So, we thought we’d share our knowledge and experience of some common tricks and traps when lodging a TPD insurance claim.
The following are some of what we commonly see in our work (in no particular order):
1. Myth: You have to be “totally” and/or “permanently” disabled to claim TPD
The words “total” and “permanent” disablement often leave people thinking that they need to be catastrophically disabled to claim a TPD benefit. In fact, that is simply not the case.
To claim, you generally need to show that you’re not able to do the work that you were doing before you stopped work or could do using your transferrable skills. You can learn a bit more about claiming TPD in our blog “What is a TPD claim?”
2. Poor advice
Many people speak to their super fund or insurer and, as a result of what they are told, they are left feeling as if they’re not disabled enough to claim a benefit. If that happens, you should get advice. We will provide you with FREE advice - 03 9448 8048
3. Mixing up the dates
Under most TPD policies, for your TPD claim to be assessed under a work based TPD definition, you must have been working at the time you got sick or injured and became unable to work. If you are not working when you get sick/injured and become unable to work, your claim may end up being assessed under a more difficult TPD definition.
Sometimes, to make claims harder, insurers will say that you did not get sick/injured and become unable to work until after you stopped working (ie they may say that you ceased work for a reason unrelated to injury or illness). They, therefore, conclude that you are not entitled to have your claim assessed under a work-based TPD definition.
This can result in your claim being rejected.
Some reasons the insurer may make this decision include:
- because you accepted a redundancy (rather than resigning due to ill-health);
- because your condition had not yet been diagnosed;
- because you did not see a doctor when you stopped working;
- and other reasons.
Usually, there are ways to challenge the decisions that insurers make about why and when you became too sick to work. Do not simply accept an insurer’s decision to reject your claim. Call us for free advice. It costs you nothing to find out where you stand - 03 9448 8048.
4. Doctor v doctor
Sometimes the doctors are simply unable to agree about whether you will work again.
Usually, what we see is your treating doctors saying you will never return to work and supporting your claim, whilst the doctors engaged by the insurance company saying you will work again.
The fund/insurer will usually prefer the opinions of the doctors that they have engaged over the opinions of your treating doctors, which can be unreasonable when:
- you have only briefly consulted with the insurer’s doctors.
- the insurer’s doctors don’t know your situation or circumstances well or have got many of your details wrong in their report; or
- all of the above!
Getting medical evidence to dispute the views of the insurer’s doctors is important and can sometimes be done by your treating doctors. But, it may also require that you get reports from your own consultant or independent medicolegal doctor.
Call us for free advice about what to do when your claim is rejected due to conflicting medical opinions – 03 9448 8048
5. Death by a thousand requests
Your claim(s) started when you handed the insurance company your completed claim forms with all the details you thought they would need to assess your claim. Then they requested:
- your tax documents;
- then your Medicare documents;
- then your Centrelink documents;
- then a medical report;
- then your clinical notes;
- and then… you get the idea.
Getting and giving the insurer as many documents as you can get (even when not requested) is a good way to stop insurers from delaying your claim by requesting information bit by bit. It helps when you know exactly what they will request, like we do! If you’re getting frustrated by the piecemeal approach to your claim, get in touch for free advice to get your claim going - 03 9448 8048
Another way is to push back and refuse any unreasonable requests. The key to this is knowing which requests are reasonable and which requests are unreasonable. Pushing back on the wrong requests can delay your claim even more.
The above are just some of the many things that insurers may try to do to reject or delay your claim.
Because of tricks and traps like these, many people choose to get a lawyer to help them to make the insurance claim. The value of getting help from a lawyer is that we know how the system works. We know when it is reasonable for an insurer to request more information or documents, arrange a medical appointment with a consultant/medicolegal doctor (sometimes called an independent medical examiner -IME) or to arrange a ‘factual interview’.
If you have ceased work due to injury or illness and are considering claiming a TPD benefit or if you have claimed and are dealing with issues like those set out above, you should get in touch for a free consultation.
Melbourne: 03 9448 8048
Brisbane: 07 3013 4300
Anywhere else in Australia: 03 9448 8048
How we charge
We are Australia's best value superannuation/insurance law firm. Other law firms charge nearly double (& sometimes more than double) what we charge. So, if you get a quote from them, or have a cost agreement, ask us what we will charge you.