Total and Permanent Disability (TPD) insurance claims

claims-tpd

Follow our guide to making a successful total and permanent disability claim in Australia.

If you're making a claim on your total permanent disability (TPD) insurance then it's crucial you understand the conditions around claiming TPD in Australia. The process from submitting a claim to actually receiving a benefit payment can be a lengthy one if you don't follow the necessary steps.

Three things you need to consider before making a TPD claim:

  1. Make sure you understand the reasons why a TPD claim could be disputed.
  2. Check if you're eligible to make a claim.
  3. Follow the appropriate steps to claim, depending on whether your TPD is included inside your super fund or a standalone policy.

So your claim for total permanent disability has come back rejected… well, don't give up just yet.

Most insurers subscribe to one of two codes of practice: either the General Insurance Code of Practice (GICP) or the Superannuation Voluntary Code of Practice (SVCP). Each of these codes offers a very similar process for disputing decisions you disagree with.

This will require you to present a strong case backing up your claim, first to the insurer themselves and then to the appropriate regulatory authorities. Click below to read a short guide on the appropriate steps to follow.

Steps to follow

Why are TPD claims disputed?

finder.com.au is a comparison service and not an insurer. For clarification on whether you are eligible to receive a claim, please refer to your product disclosure statement or contact your insurer. If you are having issues with a claim or feel your insurer has treated you unfairly, you will need to contact your insurer and go through its dispute resolution process. If after this process you’re still not satisfied, you can contact the Financial Ombudsman Service.

Am I eligible? Click on the buttons below to jump to the appropriate section

When can I make a claim?

You can make a TPD claim if you satisfy the conditions set in the policy by the insurance company or super fund that holds your cover. This usually involves showing that you're no longer able to work. Insurers will typically look at the following criteria when assessing TPD claims. Note that criteria will vary from insurer to insurer.

Understand your insurer's criteria

  • It is extremely important that you are clear on what your policy requires in order for you to make a claim as well as the definition your policy falls under to avoid any surprises in the event of a disability.
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What criteria is used to assess my claim?

The criteria that insurers use to determine eligibility for payment include the following:

  • 1. Level of disablement

Some insurers will require a minimum level of disability. They will also look at the likelihood of you recovering from the disability.

  • 2. Did you buy cover inside super?

A TPD policy inside of superannuation will only cover an any-occupation disability. A TPD policy outside of superannuation may cover both own-occupation and any-occupation disability claims.

  • 3. Own or any occupation?

Your TPD cover will typically fall under either an own-occupation cover or any-occupation cover. You'll need to meet the definition of your policy to be eligible for a claim.

  • Own occupation. This is when you are unlikely to ever return to full-time work in your previous job.
  • Any occupation. This is when you are unlikely to ever be able to engage in any form of regular paid work again. This form of disability is harder to prove.
  • 4. Waiting periods

There is usually a minimum waiting period from the time you apply before you can make a claim.

  • 5. How long have you been working?

Some insurers require you to meet a minimum level of work before you're eligible.[/fin_tab]

  • 6. Your ability to perform daily activities of living

For some policies (e.g. living expenses cover), you're required to demonstrate an inability to perform a certain number of daily living activities. Daily activities can refer to the following:

  • Bathing or showering
  • Eating and drinking
  • Using the toilet
  • Dressing and undressing
  • 7. Ongoing medical care

Some policies require you to show ongoing medical care to improve your condition or to prevent further illness.

How does criteria vary between insurers?

The following chart highlights the various criteria that different insurers may have before accepting your claim.

Criteria Common variations between insurers*
The extent of your disability
  1. You're unlikely to return to any type of work.
  2. You're unlikely to return to your previous role.
  3. You have lost a limb or suffered a serious injury.
Own vs any occupation
  • Own occupation. The definition of "current occupation" will vary. For example, if a piano player suffers a hand injury and can no longer perform professionally but can still teach piano, some insurers might classify teaching as the same occupation while others may consider it to be different.
  • Any occupation.The definition of "any occupation" also varies. Medical advances, such as prosthetics and similar advances in the workplace, can make an insurer less likely to classify someone as unable to work in any job.
Waiting periods
  1. Three-month continuous absence from work
  2. Six-month continuous absence from work
  3. No waiting periods for some conditions such as major head trauma
Minimum work history
  1. Show 12 months of employment before a claim can be made
  2. Full-time employment
  3. Not full time but with minimum hours
Loss of independence
  1. You have to show that you are unable to perform two to three daily living activities.
  2. Evidence in the form of a diary may sometimes be required.
Ongoing medical care
  1. Regular appointments, advice and care of a medical specialist
  2. Regular care of a medical practitioner
  3. Rehabilitation

*This is not an exhaustive list of variations. Always check the product disclosure statement (PDS) of your policy for exact eligibility requirements. Source: Australian Securities and Investment Commission


How do I make a TPD claim? Key steps

The appropriate steps will depend on whether you bought your cover inside a superfund or outside of it.

How do I make a TPD claim inside of my super fund?

Some superannuation funds offer a default level of TPD cover for members. You can check if there is TPD cover in your super fund by contacting your fund representative and requesting a copy of your online statements.

Steps to follow

  1. Contact your super fund. You will need to contact your super fund and provide the necessary claim documentation. You might also need to provide the following additional documentation:
    • Identification, such as a birth certificate, driver's licence or passport
    • Existing medical reports
    • Medical evidence to support claim
  2. Submit your claim. You need to sign your claim statement and attach all necessary documentation, which you will then give to your case manager. Your case manager will provide assistance throughout the claim process and help ensure that all of the necessary documentation is received.
  3. Your case manager organises the claim. Your case manager will assess your claim to determine whether you are eligible to receive a TPD benefit. The case manager will usually contact your employer to receive a written statement as to why you ceased work.
  4. Your insurer assesses your claim. Your insurance provider will then assess the documentation that you submitted. In some cases, the insurer may request further evidence, such as the following:
    • Doctor reports
    • Further medical examination from an independent specialist
    • Further information from your employer
    • Further information from you
  5. Your insurer accepts or rejects your claim. After assessing all the information provided, the insurance provider will make the following determination:
    • Accepted. Your insurer accepts your claim and contacts you with claim payment options.
    • Declined. Your insurer denies your claim because you have not satisfied the conditions of the policy.
    • Deferred. Your insurer defers your claim in order to do a further assessment on the full extent of your disability and its permanency.

If your insurer defers or declines your claim, it will be referred to the fund trustee who will review the decision made by the insurance provider on your behalf.


How do I make a claim outside of my super fund?

Claiming standalone TPD insurance is similar to claiming TPD held inside of your superannuation, although there are some differences between the two processes. Each claim process may differ depending on the type of claim and the insurance provider, although you will generally need to take the following steps:

Steps to making a TPD claim

  1. Contact your insurer's claims team. You can get the necessary forms from the claims team. Your financial adviser may assist you in filling out the documents if necessary.
  2. Prepare necessary documentation. You will need to provide the following documentation:
    1. Completed claim forms
    2. A statement completed by a certified medical practitioner verifying your illness/injury
    3. Bank details so your insurer can deposit any benefits into your account
    4. Details of previous health claims
  3. Submit claims documentation. You need to complete the claim documentation and submit it to the insurance provider.

How do TPD claims work for multiple super funds?

Many people have TPD insurance that has accumulated in multiple funds that have been opened by different employers. In some circumstances, you may be able to claim multiple benefits at the same time. However, it is important that you carefully check the conditions of each fund before submitting multiple claims at the same time.

Is there a time limit on super fund claims?

There is no time limit on when you can make a claim for a TPD benefit payment held within a super fund. That said, there are time limits on when you can appeal a refusal of a TPD claim. Legislation states that the Superannuation Complaints Tribunal can only review a complaint that has been made within two years after the trustees have made a decision regarding a claim.Back to top


Mental illness, claim denials and complex terms

How do I make a claim for depression and other mental illnesses?

It can be difficult to prove that you are unable to return to work on account of mental illness. The episodic nature of mental illnesses can make it difficult for a diagnosis to be formed.

Considerations for a TPD claim related to depression and mental health

  • Your insurer will look at the type of treatment prescribed by a health professional and the regularity of your treatment. This consideration is of particular importance for claims that are late in submission.
  • Your insurer may defer the benefit payment for a mental health claim if the insurer believes that the permanency and severity of your condition is not determined. This deferral can last until all treatment options have been tried.
  • Your insurer will assess if you are able to perform your duties at another place of employment or if you could continue work by adjusting your duties.

What if my claim gets denied?

In the event that your insurer denies your claim, you can ask for a review by following these steps:

Start with the insurer

  1. Understand why you were denied. Is the insurer claiming your cover was expired? Are they claiming your disability was caused by a pre-existing condition that was excluded from your policy? Understanding why insurer reached their conclusion will help you put together a more effective counter-argument.
  2. Put together your case. Re-read your policy in detail to make sure you're not misunderstanding any key points. Then type a letter stating why you think the decision was wrong and gather any additional supporting evidence you may have missed when you originally submitted the claim. For example, maybe you were able to dig up medical evidence proving your disability was not caused by an excluded pre-existing condition.
  3. File a dispute with the insurer. All financial providers who have signed their relevant code of practice are required to have an internal dispute resolution process (IDR). Send your case in writing to your insurer's resolution department and they will review your case independently from the claims department that originally reviewed your case.
  4. Wait. Insurers have 45 days from start to finish (90 days for funds within super) to make their final decision, although they do have to communicate with you at reasonable intervals during that time.

If things still don’t work out

You still have options at this point:

  1. Take it to the regulatory authorities. If your claim comes back denied again, or the insurer hasn't made a decision within 45 days (90 for super), you can take the complaint to the appropriate regulatory authority. For normal insurers, that's the Financial Ombudsman Service (FOS). For insurance within super, that's the Superannuation Complaints Tribunal (SCT).
  2. Take legal action. If the relevant regulatory authority doesn't rule in your favour, there is nothing stopping you from hiring a lawyer and taking your case through the external justice system.

Why do life insurance claims (including TPD) get disputed?

Type of claim dispute Percentage of total claim disputes
Evidence 25%
Delay 22%
Underpaid 16%
Definitions 12%
Eligibility 7%
Non-disclosure 5%
General denial 5%
Limitation period 2%
Overpaid 1%
Reason not provided for denial 1%
Waiting period 1%
Approved claim with late or no payment 1%
Income protection ceased 1%
Sickness vs injury 0%
Customer service 0%
Miscellaneous 1%

Duty of Disclosure

When looking for TPD cover, you have to disclose any relevant information requested by the insurance provider to allow them to assess your situation. This is known as a duty of disclosure. Duty of disclosure is legally binding and you must disclose any relevant, known information to avoid the legal consequences of not informing the underwriter about information that may affect the policy. If you fail to provide this information and your policy is less than three years old, the insurer can terminate the contract. If the insurer finds that you haven't disclosed the relevant information, they may reduce the sum insured in accordance to the premium that would have been payable had the correct information been disclosed at the time of application.

Claims for partial disability

Some insurance providers will provide a partial disability benefit. This means you will have cover for any income lost if you can only work at a reduced capacity because of sickness or injury. An approved medical practitioner must certify your partial disability.

Benefits may be paid out under the following options:

  • Hours based. You will receive benefits if you cannot work the same number of hours as you could before the disability. To qualify, you will need to earn less than you did before your disability and be under medical care.
  • Duties based. You will receive benefits if you are unable to perform all the duties essential to your previous job and are making less income as a result.

This benefit is determined using the following formula:

(Pre-disability income - post-disability income) / (pre-disability income x monthly benefit) Some policies will provide partial payment if you suffer certain disabilities. This may include the permanent loss of the use of the following:

  • Loss of one arm
  • Loss of one leg
  • Loss of sight in one eye

Compare TPD insurance quotes from these direct brands

Product details Maximum cover Maximum Entry Age Cooling-off
(days)
NobleOak TPD Insurance
NobleOak TPD Insurance
Get fully underwritten Total and Permanent Disability Insurance that can be customised to fit your occupational situation and financial circumstances. $5,000,000 64 30 Get quoteMore info
Real TPD Insurance
Real TPD Insurance
Optional TPD cover available with Real Family Life Insurance. Get up to $1 million in cover against total and permanent disablements. $1,000,000 64 30 Get quoteMore info

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REPORT 498: Life insurance claims: An industry review

William Eve

Will is a personal finance writer for finder.com.au specialising in content on insurance. While he cannot give personal advice to clients, Will enjoys explaining the intricacies of different types of protective cover to help individuals and businesses find affordable cover that won't leave them underinsured.

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28 Responses

  1. Default Gravatar
    LesleyJanuary 10, 2018

    What should I do when someone I know well is claiming tpd through the court system, due to a accident at work. However he was injured but not TPD therefore his claim is fraudulent.

    • finder Customer Care
      HaroldJanuary 10, 2018Staff

      Hi Lesley,

      Thank you for your inquiry.

      If you have any concerns or issues with a claim you will need to contact your insurer and go through its dispute resolution process. If after this process you’re still not satisfied, you can contact the Financial Ombudsman Service.

      I hope this information has helped.

      Cheers,
      Harold

  2. Default Gravatar
    MikeSeptember 14, 2017

    Just wondering how long it generally takes to receive a TPD payment once it has been approved and an amount agreed upon?

    My partners TPD claim has just been approved and we’re waiting for the payment to assist with some medical bills.

    Thank you

    • finder Customer Care
      MaySeptember 14, 2017Staff

      Hi Mike,

      Thank you for your inquiry.

      Basically, the timeframe would take longer like months. I would suggest that you speak to your super fund to inquire and confirm.

      Cheers,
      May

  3. Default Gravatar
    AngelaJune 9, 2017

    I doubt whether to go ahead or not with my TPD claim. I have a mental condition and haven’t worked for 7 years. I have a proof indicating the severity of my illness. My doubt is about recovery, even though my mental illness just seems to get worse with age. I don’t know if I have any chance to recover.

    I would like to find out if I have a chance to have this claim accepted. If it does, do I get paid lump sum and 5 years later I have recovered enough to work one day a week (I am 49)?

    I would really appreciate your advise.

    Thank you.

    • Default Gravatar
      JonathanJune 10, 2017

      Hi Angela!

      Thanks for the comment.

      Usually, the insurer has pre-defined criteria in their TPD benefits claim, including the mechanism of how you’ll get paid if approved. It is important that you go back to your policy, their Product Disclosure Statement webpage or talk to their specialist whether you meet this criteria and your chances of approval.

      Some insurers may honor partial disability (part-time workers due to their health conditions) and has their own math to know how much they’ll approve on your claim based on the lost income. This also requires that you get in touch with them for discussion.

      Should you not be satisfied about their claims review, you can go through with their internal dispute process. If you’re still dissatisfied with the outcome, you may avail of Financial Ombudsman Service.

      Hope this clarifies.

      Cheers,
      Jonathan

  4. Default Gravatar
    koutabexMay 8, 2017

    if i have had a successful tpd claim am i able to obtain my file and a copy of the supporting documents used to lodge the claim? is there some sort of freedom of information act or can i request my file from the super company?

    id like to obtain my file for my records & to verify a few things my solicitor is saying relating to the claim.

    also wondering if my file from the super company which i have successfully claimed through could somehow support a claim with a different super company?

    • finder Customer Care
      ZubairMay 9, 2017Staff

      Hi Koutabex,

      Thank you for your inquiry.

      You may receive some documentation from your insurer after a successful claim.

      Cheers,
      Zubair

  5. Default Gravatar
    koutabexMay 8, 2017

    can you make a claim directly to the underwriting insurance company or does it have to be through the super company?

    • finder Customer Care
      ZubairMay 9, 2017Staff

      Hi Koutabex,

      Thank you for your inquiry.

      Generally, you will notify about your claim to the super fund and they will rise it to the insurer. For further clarification on this matter please get in touch directly with your insurer.

      Cheers,
      Zubair

  6. Default Gravatar
    koutabexMay 8, 2017

    is a tpd claim affected in anyway if the super company changed hands between the date last worked and the date you lodge a claim?

    • finder Customer Care
      ZubairMay 9, 2017Staff

      Hi Koutabex,

      It depends on the conditions of the super fund so it’s a good idea to get in touch directly with your super fund for the clarification on this matter.

      Cheers,
      Zubair

  7. Default Gravatar
    koutabexMay 8, 2017

    I’ve been told there was a legislation change in 2013 and after this automatic TPD cover was applied to my account where prior to this i did not have TPD insurance.
    The date i last worked was in 2012 – before the legislation change. is there anything i can do about this or is it just too bad i wasn’t covered?

    • finder Customer Care
      ZubairMay 8, 2017Staff

      Hi Koutabex,

      Thank you for your question.

      finder.com.au is a comparison and information service and we are not permitted to provide our users with personalised financial advice or product recommendations.

      Note: Most superfund that offers TPD cover will usually have a requirement where you are working at the time of cover instated. For clarification on whether you are eligible to receive a claim, please refer to your product disclosure statement or contact your insurer.

      All the best,
      Zubair

    • Default Gravatar
      EmmaMay 8, 2017

      Thanks for your reply.

      Can I ask in general terms when the legislation changed in 2013 and TPD insurance automatically got applied was there anything put in place or any part of the legislation that addressed change from no TPD insurance or is there any sort of special considerations given to those who prior to the 2013 legislation change did not have TPD insurance and now hold it? Or is there any alternate ways to lodge a claim if this situation should arise. Generally speaking.

    • finder Customer Care
      ZubairMay 9, 2017Staff

      Hi Emma,

      Thank you for your inquiry.

      finder.com.au is a comparison and information service and we are not permitted to provide our users with personalised financial advice. However, You can get help from Insurance Law Service.

      Cheers,
      Zubair

  8. Default Gravatar
    CraigFebruary 27, 2017

    Can I claim my TPD, I was abused as a child which now has caused severe mental illness, I also have a issues with my spine I have spondylitis etc

    • finder Customer Care
      ZubairFebruary 28, 2017Staff

      Hi Craig,

      Thank you for your question.

      You have contacted finder.com.au, we are a comparison and information service and not an insurer. To find out whether or not you can claim for any conditions on your policy, it is a good idea to get in touch with your insurer or your super fund (if you’re TPD is included in your super).

      Note: TPD included in your superannuation will only cover disabilities if your disability leaves you unable to work in any type of job again.

      All the best,
      Zubair

  9. Default Gravatar
    lanaDecember 29, 2016

    My Tpd claim thru my super has been approved my insurer can I draw on the insurance part of the claim only without having to take out all my super as the insurance part is non preserved

    • finder Customer Care
      RichardJanuary 4, 2017Staff

      Hi Iana,

      Thanks for getting in touch. finder.com.au is a comparison service and we are not permitted to provide our users with personalised financial advice. As claims processes vary between insurers, you should contact your fund for the specifics.

      All the best,
      Richard

  10. Default Gravatar
    SeanOctober 19, 2016

    John,

    Insurers will do everything they can to delay and delay. In truth they will make one move every one to two months as they will do their best to hold your money as long as possible. The ombudsmen is no help for a claim that is in progress regardless of the length of time taken. The insurer will claim that they are going through the review process blah blah etc and that there have been unexpected delays blah blah and nothing will be done. The ombudsmen is of use if the claim is an approved one and payments are routinely late etc.

    The only option is to get a lawyer and then escalate to litigation as soon as practicable. in reality, the lawyer will most likely refer you for any necessary medico-legal reviews to help prove the case so it will still take some months.

    Most of the big firms (Slater Gordon for eg) work on a no win no fee and fees are deducted from the final settlement. There is also a good chance that the insurer will agree to cover a large portion of these including medico-legal costs and a percentage of lost interest -this is what happened in my case.

    Trust me. It’s the only way.

    • Default Gravatar
      vNovember 10, 2016

      This a question for Sean who posted the first comment.

      What have you learnt from engaging lawyers to handle the claim for you?

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