What to do if your TPD or income protection claim has been rejected

TPD claim rejected or income protection claim declined? What to do next

If your Total and Permanent Disablement (TPD) claim has been rejected or your income protection claim has been rejected, it can be stressful, frustrating and financially worrying. However, a rejected claim does not always mean the matter is over.

There are many reasons why a disability insurance claim, such as an income protection insurance claim or a TPD insurance claim, might be rejected or declined. In some cases, the issue may be insufficient supporting evidence. In others, the insurer may decide that the policy definition has not been met.

Whatever the reason, there may be options to review, challenge or appeal TPD claim decisions or to appeal income protection claim outcomes.

Know the terms of your insurance policy

It pays to understand why your income protection claim was declined or your TPD claim was rejected. Each insurance policy will have its own definitions that need to be satisfied in order to receive an insurance benefit, and many of these definitions interlink with each other. In our experience, it is important to obtain a copy of the full policy document, not merely rely on extracts inserted into an insurer’s reasons for declining your claim.

Common reasons income protection claims are denied

Some common reasons for income protection and TPD claims being rejected include that:

• The claimant did not meet the policy definition of disability for their specific claim type;
• The claimant did not have the support of their doctor or doctors;
• The policy was not active at the time of injury or illness;
• The claim was lodged with insufficient supporting evidence.

Three options to review a rejected TPD or income protection claim

If your claim has been rejected, you may have more than one pathway available to review the decision. The right option will depend on the type of policy, whether the cover is held through superannuation or directly with an insurer, the reasons for the decision and the evidence available to support your claim.

Step 1: Internal review with the insurer

ou should always seek to have a rejected income protection or TPD claim reviewed by the insurer through its internal review or complaints process. When the insurer notifies you that your claim has been denied, it is also required to provide you with information on how and where to request a review of the decision. 

At this very important stage, make sure that you clearly set out why you feel the decision to reject your claim was wrong and provide supporting evidence to substantiate those reasons. Insurers do not always get it right the first time, and there is no cost to you to seek an internal review. The review or complaint process is handled by someone different from the original decision-maker, and they quite often sit within a separate department within the insurer. 

A review of a decision should also be handled relatively quickly in comparison to the length of time that it may have taken for them originally to decline your claim. This is relevant for all types of insurance claims, not just income protection claims or TPD claims against disability insurance cover held within a super fund.

Step 2: External review through AFCA

If the internal review process is not successful, the next step could be to submit a complaint through the Australian Financial Complaints Authority, known as AFCA. AFCA is a free, independent complaint resolution scheme for financial disputes, including some insurance and superannuation complaints. AFCA can consider complaints about superannuation products, including decisions about disability claims involving insurance cover held through a superannuation fund. AFCA also deals with insurance complaints, including life insurance, income protection, trauma and TPD policies.

AFCA has different rules and time limits depending on whether your complaint relates to an insurance claim through a super fund or directly with an insurer. Due to the strict time limits, we recommend you make your complaint as soon as possible after receiving the decision of the internal review process. 

AFCA’s dispute resolution process is designed to be accessible and there is no application fee. AFCA can resolve your complaint in a number of ways, including payment of an amount of money, although limits or caps may apply depending on the type of complaint.

Step 3: Take your matter through the court system

If the internal review process fails and your complaint to AFCA does not deliver the payout you are seeking, you can issue court proceedings. It should be noted, however, that unlike the internal review process and the AFCA process, which are both free to pursue, court proceedings can be costly, time-consuming and stressful. Before starting court proceedings, it is important to obtain TPD insurance legal advice so you can understand the risks, likely costs, evidence required and prospects of success.

Can I appeal a rejected TPD claim?

es, you may be able to challenge or appeal a rejected TPD claim, depending on the policy, the reasons for the decision and the evidence available.

If you are wondering how to appeal a rejected TPD insurance claim, the first step is usually to obtain the full policy documents, the insurer’s reasons for denial, and all medical and employment evidence relied on in the original decision. A TPD lawyer Australia-wide can help assess whether the insurer applied the correct policy definition, whether relevant medical evidence was considered, and whether further evidence may strengthen your claim.

How to challenge a rejected income protection claim

If you want to know how to challenge a rejected income protection claim, start by reviewing the insurer’s reasons carefully. Income protection claims may be rejected because of policy wording, medical evidence, waiting periods, work capacity assessments, exclusions or disputes about whether you satisfy the policy definition. 

An income protection insurance lawyer can help you understand the reasons for the rejection, prepare submissions, gather further evidence and consider whether an internal review, AFCA complaint or court action is appropriate.

How long does a TPD claim appeal take?

The time it takes to review or appeal a rejected TPD claim will depend on the insurer, the complexity of the medical evidence, whether further reports are needed, and whether the matter proceeds to AFCA or court. An internal review may be quicker than an external complaint or court process, but each matter is different. Getting advice early can help you avoid delays caused by missing documents, incomplete evidence or unclear submissions.

Get help from an experienced disability insurance lawyer

t Hall Payne Lawyers, we assist with a range of disability insurance claims, including TPD, income protection and trauma insurance. We can help you understand the reasons your claim was rejected so you can make an informed decision on whether to review the decision with our assistance.

If you have not yet commenced your claim, having someone on your side who understands the claims process, the insurer’s obligations and the legal terminology is often the difference between having your claim accepted or rejected by the insurer in the first instance. 

If your disability insurance claim has been denied, is taking too long, or you have concerns about TPD, income protection, trauma insurance or death benefits, get in touch with a member of our superannuation and insurance team.

Contacting Hall Payne Lawyers

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 you are wondering what to do if your TPD claim is rejected, what to do if your income protection claim is denied, or how to challenge a rejected TPD insurance claim, Hall Payne Lawyers can help you understand your review options and the evidence that may support your claim after a TPD claim rejection decision.