Successful TPD claims can sometimes happen even after an insurer has initially denied the claim. This case shows why policy wording, timing, TPD claim medical evidence and careful claim strategy matters when pursuing a TPD benefit.
We assisted our client with three separate TPD claims over six years ago. The claims were based on his mental health condition, which was preventing him from being able to work. At that time, two of the claims were accepted, with one being declined in 2019.
This particular client had three active superannuation member accounts, each with a different superannuation fund. All of those member accounts held insurance cover for total and permanent disablement, known as TPD. After we carefully reviewed each policy, it was established that he would be able to make a TPD claim against all three, but it was imperative that we submitted these claims in the correct order.
One policy included a clause that stated that a TPD benefit was not payable in circumstances where an insured member had already been accepted as totally and permanently disabled by another insurer. Due to that clause, we had to ensure that this claim was submitted and finalised first before proceeding with the other two claims.
Our client was subjected to regular and ongoing workplace harassment and bullying, which caused the onset of depression and alcohol abuse. As a result, he had not been able to work since early 2016. His mental health continued to deteriorate over time. Several doctors had differing medical opinions regarding his actual diagnosis, which ranged from an adjustment disorder through to delusional psychosis.
At the time this claim was denied, over six years ago, we advised our client on the prospects of having the decision reviewed. He instructed us not to appeal that decision; he continued to be unwell and was also dealing with other extremely difficult personal circumstances at that time. When a TPD claim is denied, and you do not agree with that decision, there are options to appeal that decision. You can read more about this in our blog, “What to do if your TPD or income protection claim has been rejected”.
We encouraged him to advise us if his circumstances or health changed so we could look at the claim again for him at a later date.
We spent a lot of time providing the insurer with additional information and submissions regarding the medical and other evidence in support of our client satisfying the policy definition of total and permanent disablement. That definition differed slightly from the other two policies as it used the phrase “unable ever to engage in any gainful occupation, business, profession or employment”. By comparison, the other two policies used the phrase “unlikely ever”.
The insurer did not accept the bundle of evidence, preferring to rely on the report of an independent specialist who examined our client in early 2019. That specialist made a comment about the possibility of our client’s condition improving at some point in the future if he commenced and maintained an optimal treatment regimen.
The insurer’s decision record acknowledged that our client was unlikely to return to work in the industry he was working in when he became unwell. Ultimately, its decision to decline his TPD claim was based on the fact that our client was 45 years of age and had another 20 years within which to receive treatment, improve his overall prognosis and then undertake occupational goals with the aim of returning to the workforce. The insurer could not determine that he was “unable ever to engage in any gainful occupation.”
Despite the denied TPD claim, we remained in contact with our client every six months or so to ensure he was okay. Fast forward five years, with a lot happening to our client in between, and our client continued to send us updated medical evidence. By the end of 2024, we had enough additional evidence to support our original argument that, even with alternative treatment, he was never going to be able to return to any form of suitable employment.
Despite the passage of time and a complex set of personal circumstances, we prepared the updated medical evidence and new submissions for the insurer to review its original decision. In this particular client’s case, his original mental health condition did improve slightly, but he was never in a position to contemplate a return to the workforce on that basis. He had maintained recommended medication and treatment throughout that time. Unfortunately, he was also diagnosed with Bipolar Affective Disorder, which further compounded his disability.
We were successful in our pursuit of his final TPD claim after such a long time. Having reviewed the updated medical evidence, the insurer accepted the claim, and our client was paid $72,000 in TPD benefits. Our client is now in a position where he has additional funds available to assist with his ongoing treatment requirements and improve his overall quality of life.
This is a good example of a successful TPD claim story in Australia, particularly where a claim has previously been denied but the person continues to be unable to work due to the same illness or injury.
This matter shows that a denied TPD claim is not always the end of the process. In some circumstances, a TPD claim approved after years of rejection may be possible where new evidence becomes available, the person remains unable to work, and the original decision can be reviewed. It also shows the importance of understanding TPD claim eligibility, the exact wording of the policy, and the medical evidence required to support the claim.
A TPD claim settlement will depend on the policy, the evidence, the insurer’s assessment and the person’s individual circumstances. No outcome can be guaranteed, but properly prepared evidence and submissions can make a meaningful difference.
In most cases, it does not matter how long ago your illness or injury prevented you from working. To be able to make a TPD claim against insurance held within super, you do not need to hold the cover now, but you will need to have held the cover at the date that you were forced to cease working because of your ill health.
At Hall Payne Lawyers, we assist clients with determining if they have a potential claim available to them and prepare it on their behalf to ensure it has the best prospects of succeeding.
You can contact us by phone or email to arrange your consultation, either face-to-face at one of our offices, by telephone or by videoconference.
If your TPD claim has been denied, delayed or become difficult to pursue, Hall Payne Lawyers can help you understand your options. Our TPD insurance lawyers can review your policy, assess the evidence and explain whether you may have grounds to challenge the insurer’s decision or continue your claim. Before assuming your TPD claim is over, speak with an experienced TPD lawyer in Australia about your options.
Yes, a TPD claim may be approved after rejection in some circumstances. This may happen where further medical evidence becomes available, the insurer reviews its earlier decision, or the person can better show that they meet the policy definition.
You may be able to make a TPD claim years later if you held the relevant insurance cover when you stopped working because of injury or illness. The policy wording, timing, and evidence will need to be reviewed but it is possible for a TPD claim to be accepted after appeal.
After a TPD claim is rejected, you may be able to request an internal review, make a complaint to AFCA, provide further evidence or consider other legal options. The right step will depend on the reasons for the denial.
The time a TPD claim takes to approve depends on the insurer, the policy, the medical evidence, the complexity of the condition and whether further information is required. Some claims are resolved quickly, while others take much longer.
There is no guaranteed way to win a rejected TPD claim, but strong medical evidence, clear work history, policy analysis and well-prepared submissions can help support a review or appeal.
A TPD claim assessment usually involves reviewing the policy definition, medical evidence, work history, education, training, experience and whether the person is unlikely or unable to return to suitable work.
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