If you become sick or you’re injured and that illness or injury causes you to stop work, you may have disability insurance like TPD under a policy with an insurer or inside superannuation that provides a lump sum benefit.
We’ve run and won many TPD claims with significantly complex and tricky hurdles to overcome. In this blog, we review just one of those success stories which delivered our client $1.25 million dollars in TPD benefits that may ordinarily have been lost to them.
You can read more detail about TPD and securing a successful claim in our earlier blog, “Your guide to making a successful TPD claim”.
Case Review – TPD claim due to PTSD and a physical injury
Ellie (a pseudonym) came to us in early 2023 for help with her TPD claim, which had already been lodged and declined. Ellie was a teacher who suffered a physical injury and PTSD.
Claim declined due to opinion of doctor chosen by insurer
Ellie’s TPD claim had been declined in 2020 on the basis that Ellie had been examined by a doctor chosen by the insurer and that doctor had said that Ellie’s physical injury may improve. On that basis, the insurer could not decide Ellie was TPD.
Ellie sought advice from us. We took over the conduct of her TPD claim, lodged an internal appeal and were able to get her claim approved after a heavily disputed internal appeal process.
Learn more about options to appeal a TPD decision in our earlier blog, “Three options to appeal a rejected insurance claim”.
Proving Ellie’s physical injury was unlikely to improve was difficult
Insurers regularly rely on medical opinions that support a claimant’s condition is likely to improve, as a reason to deny their TPD claims.
In this case, we needed to obtain medical evidence regarding how likely further improvement in Ellie’s condition was and whether that further improvement would even be enough to enable her to return to work as a teacher.
As soon as we were engaged, we obtained updated medical opinions from Ellie’s treating doctors, as it had been two years since her claim was declined. These reports supported that Ellie was TPD and confirmed that Ellie’s medical conditions were not expected to improve to such an extent that she could return to work as a teacher.
Ellie’s PTSD had not been considered by the insurer
We noticed when reviewing Ellie’s claim file that when the insurer declined the claim, they had failed to consider the effect her mental health condition had on her. We, therefore, obtained medical evidence regarding her mental health condition, which had become more disabling than her original physical injury.
Complaint lodged against the insurer
Once we had obtained the medical evidence needed to support the claim, we lodged a complaint with the insurer. We made lengthy submissions in reference to the earlier medical evidence from 2020 that supported an approval of the claim, and which the insurer had largely ignored when declining the claim.
The insurer requested further medical reports from Ellie’s treating doctors and other documents that they had not obtained during the original claim (including financial documents).
The insurer strongly resisted paying the claim. During the internal appeals process we had to continually advocate for the approval of Ellie’s claim and apply pressure on the insurer to decide the claim.
The insurer took 15 months to decide the claim after we lodged our internal appeal and finally approved the claim in late 2024, almost five years after it had first been lodged.
If you’ve lodged a TPD claim (or other disability insurance claim like income protection or trauma insurance) and the insurer is taking a long time to make a decision, you should seek legal advice about your options. You can read more about this in our earlier blog, “Is your insurance claim for TPD taking too long?”
A challenging yet well-deserved win delivers $1.25m in benefits
We were able to get Ellie’s claim approved after 15 months of advocating for her. Ellie was finally paid a TPD benefit of approximately $1,250,000. As Ellie hasn’t been able to work for five years, the TPD benefit will go a long way for Ellie and her young family.
Because of the extended delays in the assessment of Ellie’s claim, we will be acting for her in a claim for interest on the TPD benefit, which we estimate could exceed $100,000.
The importance of getting legal advice if your TPD claim is declined
Had Ellie not sought legal advice, the insurer’s decision to decline her claim in 2020 would have held, and would never have been overturned.
This case is a good example of why it is important to seek advice from a lawyer experienced in disability insurance claims as early as possible, especially if your claim has been declined on the basis that your medical condition might improve. From our experience, the earlier clients seek advice from us, the more likely we can help them obtain the medical evidence they need for their claim to be approved and achieve a successful outcome for them.
Get help from a disability insurance lawyer
This TPD payout has changed Ellie’s life. If you’re having difficulties with your insurance claim (unsure what disability insurance you have, declined claim, delays by the insurer, unsupportive medical evidence etc), get in touch for some free advice. It costs you nothing to find out where you stand, and we run claims on a “no win, no fee” basis.
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