A TPD claim can provide vital financial support when illness or injury causes you to permanently stop working. However, these claims are often complex, with strict definitions and detailed evidence requirements to optimise the success of a claim.
Below, we explore some of the main challenges people face when making a TPD claim and how to manage those challenges.
What medical evidence do I need for a successful TPD claim?
Medical evidence is the foundation of every TPD claim. To qualify, you must show that your illness or injury causes you to permanently stop working. The insurer will usually require medical reports from your treating doctors and specialists confirming your diagnosis, treatment, and long-term prognosis.
Importantly, TPD benefits will usually be paid if your condition means you are unlikely ever to work again in your usual job or, in some cases, any job suited to your education, training or experience. This means that, in most cases, you don’t have to be completely unable to do all work, just work that you are qualified to do.
Common challenges with getting supportive medical evidence for TPD claims
- Incomplete or unclear medical reports
Insurers may delay or reject claims where reports don’t directly address your long-term work capacity.
- Conflicting medical opinions
Insurer-appointed medical examiners (IME or medicolegal doctors) may disagree with your treating doctor’s opinion and this causes delays or rejections.
Further reading: “What to do if your superannuation TPD claim is rejected”
- Inconsistent dates or wording
Your doctors need to clearly state when your condition first stopped you from working and whether your situation is permanent.
- Uncertainty
Doctors may be unwilling to say you can’t work again, because they don’t know what the future holds or they are worried about being sued if they are wrong.
Medical evidence that can strengthen your TPD claim
- See your doctor regularly and clearly explain your symptoms and difficulties at work. Make sure they know you are genuine and have tried to recover or get back to work.
- Ask your doctor or specialist to explain, in plain language, why you can’t return to work and whether this is likely to change.
- Ensure your certificates and reports are consistent about your diagnosis, incapacity dates, treatment, and prognosis.
Do I have to show that I can’t work again in my old job or any job?
This depends on the definition of TPD in your insurance policy. Most superannuation-based TPD policies use one of two definitions:
- “Own occupation” – you must show you’re unlikely ever to work again in your usual job or field at the time you became disabled.
- “Any occupation” – you must show you’re unlikely ever to work again in any job suited to your education, training, or experience (sometimes with a retraining clause also).
Most superannuation TPD policies use the “any occupation” definition (particularly those which are held in super), which is harder to satisfy.
Common problems associated with TPD definitions related to work capacity
- The insurer argues that you could still perform lighter or alternative duties.
- Your past work experience or qualifications suggest you can still work despite your illness/injury.
- Your treating doctor’s report focuses on your old job only, not your broader work capacity.
- Your doctor says they are not sure about your diagnosis and/or prognosis. This is common for claims related to illnesses like:
- chronic fatigue syndrome (ME);
- Lyme disease;
- fibromyalgia, and others.
Tips to avoid disputes related to TPD definitions of work capacity
To improve your chances, ask your doctor to comment on your capacity for any suitable work, not just your previous job. Independent occupational assessments can also help show that you’re not realistically employable.
What if my TPD claim is assessed under an Activities of Daily Living (ADL) definition instead of a work-based definition?
Some super funds or insurers apply an Activities of Daily Living (ADL) definition of TPD instead of a work-based one. This often happens where you are not working at the time you became disabled or were working only limited hours.
Under an ADL definition, you must prove that you can no longer perform a number of basic everyday tasks without assistance. These can include feeding, dressing, bathing, toileting, or moving around.
This is a much stricter test and is often unfair for people who are genuinely unable to work but still manage their daily self-care.
Tips if an ADL definition is applied in your TPD claim
- Get legal advice and make sure that your policy is carefully checked as the application of this definition may be open to challenge if the insurer applied the wrong definition.
- If the ADL definition applies, consider providing detailed medical and functional evidence showing how your condition affects both work and daily life.
How do pre-existing condition exclusions work with TPD claims?
Most TPD insurance policies contain pre-existing condition exclusions designed to prevent claims for illnesses or injuries that existed before your insurance cover began. These clauses are a common source of dispute and confusion.
Importantly, under most TPD policies, the pre-existing condition exclusion will not apply if you were working without restriction when your cover started.
In broad terms, if a pre-existing condition exclusion applies, you may not be covered for a condition if you had signs, symptoms, or treatment for that condition before your cover started. This is the case even if it wasn’t formally diagnosed, provided you know/knew about the symptoms. If you didn’t know about the symptoms, you may avoid the exclusion.
Learn more: “Pre-existing condition exclusion clauses in disability insurance claims”
Get help from a disability insurance lawyer
TPD claims can be life-changing but are often complex and time-consuming. Success depends on strong medical evidence, understanding how your policy defines TPD, and ensuring the correct test, and not an unfair exclusion, is applied to your claim.
If you’re facing issues with medical evidence, policy definitions, or pre-existing condition exclusions, our superannuation and insurance team can help you prepare, lodge, and pursue your TPD claim.
We offer free initial advice, no upfront fees and run cases on a ‘no win, no fee’ basis.
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