If you have been unable to continue working due to a serious illness or injury, you may be entitled to make a Total and Permanent Disability (TPD) insurance claim. TPD insurance provides financial support through a lump sum payment when you are no longer able to work due to your medical condition.
Many people are unaware that they have TPD insurance because it is often included automatically through their superannuation fund. Cover may also exist through a separate personal insurance policy.
Making a TPD claim can be complex, particularly when you are dealing with the impact of an illness or injury. Understanding your policy, gathering the right evidence and following the correct claims process can significantly improve your chances of a successful outcome.
This article explains what TPD insurance is, how the claims process works and what options may be available if your claim is declined.
What Is Total and Permanent Disability (TPD) Insurance?
Total and Permanent Disability insurance provides a lump sum payment to eligible policyholders who are unable to return to work due to a permanent illness or injury.
TPD insurance is commonly included as part of a superannuation policy, although some people also hold standalone TPD insurance policies. Because this cover is often automatically included in superannuation, many people do not realise they may have an entitlement to make a claim.
A TPD policy is a contract between the insured person and the insurer. The terms of the policy determine whether a claim can be made and what evidence is required.
Important parts of a TPD policy may include:
- eligibility requirements, including age limits;
- waiting periods and exclusions;
- the definition of total and permanent disability;
- whether the policy considers your usual occupation or any occupation;
- the evidence required to support your claim; and
- the amount payable if your claim is approved.
How Do I Know If I Have TPD Insurance?
The first step in making a TPD claim is determining whether you have insurance cover in place.
You should check:
- your superannuation accounts and member statements;
- your insurance policies and product disclosure statements; and
- any correspondence from your superannuation fund or insurer.
If you are unsure whether you have TPD cover or cannot locate your policy documents, a lawyer experienced in TPD claims and superannuation insurance disputes can assist you in identifying your potential entitlements.
How Do I Make a TPD Claim?
If an illness or injury has prevented you from continuing to work and you have TPD insurance, you may be able to make a claim.
Unlike many personal injury claims, you generally do not need to prove that another person was responsible for your injury or illness. A TPD claim is based on whether you meet the definition of disability contained in your insurance policy.
The claims process generally involves:
- Reviewing your policy: Your lawyer will assess the terms of your policy to determine whether you meet the requirements for a claim.
- Gathering supporting evidence: Medical reports, employment records and information about your qualifications, training and work history may be required.
- Submitting the claim: Your insurer or superannuation fund will require specific claim forms and supporting documentation.
- Assessment by the insurer: The insurer will review the evidence and may arrange independent medical examinations.
- Claim decision: The insurer will either accept or reject the claim and provide reasons for its decision.
How Is a TPD Claim Assessed?
Each insurer and superannuation fund has its own policy wording and definition of TPD. The assessment will depend on the specific terms of your policy.
Generally, a TPD claim requires evidence that:
- you have been unable to work because of your illness or injury;
- your condition has continued for the required waiting period, often six months; and
- you are unlikely to return to work in your usual occupation or another suitable occupation, depending on the policy wording.
The insurer will consider medical evidence, including reports from your treating doctors and specialists. It may also consider information about your employment history, education, qualifications, skills and experience.
Because TPD policies can contain complex definitions, the outcome of a claim often depends on how the policy wording is interpreted and the strength of the supporting evidence provided.
What Happens If a TPD Claim Is Rejected?
Unfortunately, some TPD claims are declined by insurers or superannuation funds.
A claim may be rejected for a number of reasons, including:
- the insurer believes the policy definition of TPD has not been met;
- insufficient medical evidence has been provided;
- the insurer disputes the impact of the condition on your ability to work;
- the policy has exclusions that apply; or
- the claim was not made within the required timeframe.
If your TPD claim has been denied, you may have options to challenge the decision. This may include requesting an internal review, making a complaint through the appropriate external dispute resolution process or commencing legal proceedings where appropriate.
TPD disputes can be complex because they often involve detailed insurance policy interpretation and medical evidence. Obtaining legal advice early can help you understand your rights and available options.
Getting Legal Help With a TPD Claim
Making a TPD claim can be overwhelming, particularly when you are already managing the effects of a serious illness or injury.
An experienced TPD claims lawyer can assist by reviewing your policy, preparing supporting evidence, communicating with your insurer and helping you challenge an unfair claim decision.
If your claim is successful, a TPD payment may provide important financial support to help manage medical expenses, living costs and future financial needs.
Summary
TPD insurance can provide valuable financial protection if you are permanently unable to work because of illness or injury. However, the claims process can be complicated and insurers may carefully assess whether the requirements of the policy have been met.
If you believe you may have a TPD claim, it is important to review your superannuation and insurance policies and obtain advice about your options.
If you have TPD insurance or need assistance with a rejected claim, contact Somerville Laundry Lomax for advice about your circumstances.
This article provides general information only and is not intended to be legal advice. You should obtain professional advice relevant to your circumstances.