Roger (a pseudonym) came to us in early 2025 for help with his income protection (IP) claim, after experiencing long delays in his insurer’s assessment of the claim. Roger was self-employed and had ceased working in his business in March 2024. He lodged his IP claim in August 2024 and had still not received a decision, nearly five months after ceasing work.
Two months after meeting with Roger, we secured back-payment of the outstanding income protection benefit.
For a guide to income protection benefits, visit our earlier blog, “What is income protection and how do income protection claims work?”
Delays in claim due to issues with medical evidence and exclusions
When we were engaged, we contacted the insurer to determine why they hadn’t yet approved Roger’s IP claim and commenced payments. Under the insurance industry code of practice, insurers are supposed to decide an IP claim within two months, unless there is a good reason they haven’t been able to.
The insurer confirmed that they needed confirmation from Roger’s doctors that he had been diagnosed with Mast Cell Activation Syndrome (MCAS) and/or Chronic Inflammatory Response Syndrome (CIRS) to be able to pay the IP claim.
We were able to assist Roger by providing him with template medical certificates to take to his doctors and obtain a clear diagnosis to support his IP claim. We also identified that there were exclusions on Roger’s IP insurance policy and ensured the template medical certificates made it clear that Roger was not claiming for an excluded condition.
You can read about the importance of your doctors’ support in our earlier blog, “The importance of your doctors for a successful TPD/IP claim”.
When we provided clear medical evidence to the insurer to support an approval of Roger’s IP claim, they confirmed that they required more evidence to determine:
- that Roger’s disability was ongoing;
- that the exclusions under Roger’s policy didn’t apply; and
- that his business was not continuing to operate in his absence.
We submitted Roger’s financial information to the insurer to prove his business was not operating and assisted Roger in obtaining a further medical report from his treating doctor to support that his disability was ongoing and the exclusions under his policy didn’t apply.
You can read more about claims for self-employed people in our earlier blog, “TPD and other disability insurance claims when you’re self-employed”.
While we were assisting Roger with his IP claim, he was experiencing significant financial hardship, so we assisted him with getting a financial hardship payment from his insurer, while they finalised their assessment of his claim.
Roger’s IP claim was approved within two months of engaging us
After long delays and significant challenges in dealing with seemingly never-ending requests for information, Roger’s IP claim was approved within two months of engaging us. Roger was thrilled with the outcome, as he was under significant financial stress and considering having to permanently close or sell his business.
Roger was back-paid nearly $100,000 in IP benefits and has since engaged us on an ongoing basis to assist him with his ongoing IP claim. Roger has not had to permanently close or sell his business.
Since Roger engaged us to manage the conduct of his ongoing IP claim, we have been able to get the insurer to only require Roger to provide medical claim forms to support his ongoing payments every three months. We are continuing to try to get the insurer to only require these forms every six months, given the severity of Roger’s condition.
The importance of getting legal advice when your IP claim is delayed or denied
Had Roger not sought legal advice, the insurer may have continued delaying his IP claim or even declined it.
This case is a good example of why it is important to seek advice from a specialist lawyer as early as possible, especially if your IP claim has not been decided within a reasonable period of time.
From our experience, the earlier clients seek advice from us, the more likely we can assist and help them obtain the medical and other evidence they need for their claim to be approved and achieve a successful outcome for them.
Get help from a disability insurance lawyer
This successful income protection claim has put Roger’s life back on track. If you’re having difficulties with your insurance claim, for example:
- unsure what disability insurance you have (like TPD, income protection, trauma insurance);
- declined claim;
- delays by the insurer;
- unsupportive or insufficient 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.
Contacting Berrill & Watson
📞 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.
Further reading
- What to do if your income protection claim is rejected?
- What are the main reasons income protection claims get rejected?
- Can an insurer stop paying my income protection insurance benefits?