This case study shows how a carefully prepared total and permanent disability (TPD) claim can lead to a life-changing outcome, even where complex medical histories and pre-existing condition exclusions are involved. Our client’s recent illness left him unable to work, but a detailed review of his superannuation funds revealed multiple TPD insurance policies.
This blog explains how the TPD claims were strategically prepared, why the medical evidence was critical, and how a $2 million outcome helped rebuild his future.
Background to Timothy’s TPD claims
When we first met Timothy (not his real name), he was overwhelmed. A sudden and severe illness had left him permanently unable to work and facing the prospect of supporting himself and his family without an income.
What he didn’t realise was that, scattered across three superannuation funds accumulated during his working life, he held three separate TPD insurance policies totalling approximately $2 million.
Importantly, Timothy had this insurance cover in place (in all three policies) at the time he stopped work. If you have an injury or illness that causes you to stop work, but you don’t lodge your TPD claim for a number of years, eligibility is dependent on the insurance in place at the time you stopped work due to the injury/illness, not the date you lodge your claim.
We undertook a careful review of all three superannuation insurance policies, assisted him with obtaining the medical evidence necessary to support the three claims, and strategically managed his claims, turning what could have been three challenging claims into a fast, life-changing financial result.
Two of Timothy’s TPD policies had pre-existing exclusion clauses
As Timothy suffered from a rare genetic disorder which predisposed him to illness, we had to first review each of his three insurance policies to ensure he could claim for this disorder.
Timothy had moved between several employers over the years and accumulated three superannuation accounts with associated disability insurance policies. Each policy had different rules, definitions and importantly, two of the three policies had pre-existing condition exclusion clauses. You can read more about these clauses in our earlier blog, “Pre-existing condition exclusion clauses in disability insurance claims.”
As Timothy was diagnosed at a very young age with his genetic disorder, it was very clearly a pre-existing condition, and so he would not be able to claim two of his insurance policies for that disorder.
This meant we had to be careful to ensure that all three claims were brought on the basis of Timothy’s recent illness, rather than his genetic disorder. It is very common for insurers to request copies of each other’s claim files, so it was important to ensure the medical claim forms were consistent across all three claims.
If the initial medical documents submitted in support of the claims failed to distinguish between his genetic disorder and the recent illness that actually disabled him and caused him to stop work, two of his three claims could be declined on the basis of a pre-existing condition exclusion clause.
Preparing the TPD claims for lodgement
Although Timothy had a lifelong genetic disorder, it was not the condition that caused him to stop working. We confirmed with Timothy that his disability was caused by his sudden and recent illness.
Our claims strategy focused on making that distinction clear to the insurers.
We worked closely with Timothy and his treating specialists to prepare the necessary medical evidence, including detailed medical reports and initial medical claim forms. In doing so, we ensured Timothy’s doctors:
- clearly confirmed his diagnosis with the recent and disabling illness;
- set out a clear timeline of when the symptoms of his recent and disabling illness began;
- explained clearly that the recent illness, not the genetic disorder, caused his permanent disability; and
- confirmed that Timothy was TPD as defined under each of his three policies (as the definitions were slightly different).
While this careful preparation of the medical evidence meant the lodging of the three claims took longer, it was ultimately a key factor in the success of the three claims.
Further reading:
“The importance of your doctors for a successful TPD claim”
Timothy’s three claims were all approved within 3 months
All of Timothy’s three TPD claims were ultimately approved within three months of being lodged.
For TPD claims, particularly those involving exclusions and complex medical histories, this is an exceptionally quick outcome, as most claims tend to take between 6 to 12 months. You can read more about timeframes in our earlier blog, “Time limits for an insurer when assessing an insurance claim.”
The strength and clarity of the initial medical evidence and careful preparation of the initial claim forms played a major role in achieving this outcome.
The final amount paid to Timothy across the three policies totalled approximately $2 million.
What this meant for Timothy and his family
Given the severity of Timothy’s recent illness, it is very likely that he will never be able to return to work again. That reality weighed heavily on him when he first sought help from us.
But with the approval of all three TPD claims and the resulting $2 million paid into his superannuation accounts, Timothy has been able to:
- secure stable housing for his family;
- fund ongoing medical care and rehabilitation;
- remove financial stress from his day-to-day life; and
- put long-term financial structures in place to safeguard his family’s future.
Importantly, the payout ensures that Timothy’s family is now financially supported for the future, even though he is unlikely to ever work again.
Why this case matters
Timothy’s story illustrates several key lessons:
- Some Australians may unknowingly hold multiple TPD policies across different superannuation funds. See our earlier blog, “Can I make a claim for a TPD benefit on more than one policy or superannuation account?”
- Pre-existing condition exclusions can significantly affect claims, but they can also be navigated with the right strategy applied early in the claim. Importantly, if your TPD claim is denied due to an exclusion clause, don’t just give up. Contact us for some free advice to determine if there are options for appealing that decision.
- The illness that disables you is not always the one to which an exclusion applies. Careful preparation of the initial claim forms is important.
- A well-prepared claim lodgement with tailored medical evidence can sometimes result in a faster claim approval.
The importance of getting legal advice when pursuing complex TPD claims
Had Timothy attempted the claims process alone, the pre-existing exclusion clauses on two of his policies may have led to declined claims or substantial delays. Instead, he received all three payouts within three months.
If you’ve worked multiple jobs or moved between super funds, you may have insurance cover you don’t know about. And if illness or injury has taken you out of the workforce, understanding your policies and especially any exclusions is critical.
Timothy’s story is a powerful reminder that:
- a thorough review of your superannuation and insurance can sometimes uncover hidden entitlements;
- strategic preparation can overcome complex medical and policy issues; and
- the right help at the right time can completely change the trajectory of someone’s life.
Get help from a TPD lawyer
The approval of these three TPD claims has put Timothy’s life back on track. If you’re having difficulties with your insurance claim or are simply unsure of what your options are, please 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
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