Superannuation & TPD Insurance Claims

If you have stopped working on a long-term or indefinite basis due to an injury or illness, you may be able to make a total and permanent disability (TPD) claim. TPD insurance provides a lump sum payment in certain circumstances where you can no longer work in your usual occupation or other type of employment, taking into consideration your qualifications, experience, and training. 

Do I have TPD insurance?

Insurance for TPD may exist as a stand-alone policy or form part of your superannuation. People are often unaware that they have TPD insurance, so it is important to check your documents carefully.

The terms and conditions vary between different policies. Superannuation funds have their own criteria and TPD definitions. The process for making a claim is complex and can be confusing. Our lawyers have assisted many clients claim their TPD entitlements and have successfully challenged decisions by insurers or fund managers to deny a TPD claim.

When can I make a TPD claim?

Your entitlement to make a TPD claim depends on the requirements set out in your policy documents or superannuation fund. Generally, there is no time limit to make a claim for a TPD benefit. Therefore, even if you ceased work a long time ago, it is worth investigating and lodging a claim. Criteria varies between insurers, however some common requirements or considerations when making a claim can include:

• Demonstrating you have ceased work due to illness or injury.
• Demonstrating you have not returned to work for a period of months (called a waiting period) after ceasing work.
• Demonstrating that at the conclusion of the waiting period, you are unlikely (or unable) to ever return to work in any occupation that you are reasonably suited to by your education, training, or experience.
• A minimum level of employment before you are eligible for TPD. 

Although a TPD claim relates to an injury or illness, it is different to other types of compensation claims such as worker’s compensation or motor vehicle accident claims. Therefore, if other such claims are rejected because you do not meet an injury threshold, it does not mean a TPD claim will be rejected. Similarly, if you are not entitled to a Disability Support Pension, it does not necessarily follow that a TPD claim will not be successful. 

If you are unsure as to whether you qualify for a TPD payment, we recommend you speak to one of our experienced lawyers.

Making a TPD claim

• We will review your policy to determine your eligibility, assist with completing your claim form and help to arrange supporting evidence such as medical reports, employer statements, trade certificates and information regarding your training and experience.
• After your claim forms have been accurately completed and submitted with the superfund, your claim is then referred to their insurer for assessment.  The insurer will usually request more information as required. 
• We will liaise with the insurer or its representative and keep you informed regarding the progress of your matter.
• The insurer will then finalise its assessment and make a determination on your claim, based on the materials provided to it or it has obtained. As a claimant, you have the onus of proving that you satisfy the TPD definition, therefore it is imperative that we provide all supportive materials to the fund/insurer.

What if my TPD claim is rejected?

A TPD claim may be rejected on technical grounds or because of the insurer’s interpretation of the policy terms. This often concerns the meaning of TPD as defined in the policy in consideration of the medical evidence provided.

If your claim is denied, we will review the reasons for denial and provide guidance on challenging the decision. 

If you are not satisfied with a decision regarding your TPD claim, you may request a formal internal review by the fund trustee or insurer. 

If a satisfactory outcome is still not reached, we can discuss further avenues of review, for example, through the Australian Financial Complaints Authority (AFCA) or we can issue court proceedings. Time limits apply when challenging a decision. If you do not already have legal representation at this stage of your claim, we recommend you make an appointment with one of our lawyers.

We can help if you or someone you know needs assistance with a TPD claim. Your first interview is free and, subject to eligibility, we will act on a no-win-no-fee basis (exclusive of disbursements) or on a fixed-fee basis so you have the comfort of knowing what you will pay (if successful with your claim) right from the start.

Keep in mind that your interests and the insurance company’s interests are not aligned.  We encourage you to seek advice from a lawyer experienced in superannuation and insurance law.

If you need any assistance, please contact one of our lawyers by emailing office@paulalvaro.com.au or calling (08) 8202 0099 for expert legal advice.