How To Make A Successful TPD Insurance Claim


Need to make claim on your policy? Follow our guide to making a TPD claim in Australia.

It is crucial that all policyholders and anyone looking to take out TPD cover to have a clear understanding on the conditions around claiming TPD in Australia. The process of submitting a claim to actually receiving a benefit payment can be a length process if the necessary steps are not taken.

Three things to consider before you make a TPD claim:

  1. Understand if you're eligible to make a claim
  2. Work out if your TPD cover is included inside your superannuation or a standalone policy
  3. Follow the appropriate steps to ensure a smooth claim process

Receive a quote for TPD Insurance or review your existing cover is a comparison service and not an insurer. For clarification for whether you are eligible to receive a claim, please always refer to your Product Disclosure Statement or contact your insurer. If you are having issues with a claim or feel you have been treated unfairly by your insurer, 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.

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When can a claim be made?

A TPD claim benefit can be received when the policyholder has satisfied the conditions of TPD as defined by the insurance company or Super Fund in which their cover is held. This usually involves showing that you're no longer able to work again.

What criteria is assessed before I'm paid?

Common forms of criteria that insurers will use to determine eligibility for payment include:

Insurers will typically look at the following criteria when assessing TPD claims. Note: Criteria will vary from insurer to insurer.

CriteriaWhat's this mean?
The extent of your disablementSome insurers will require a minimum severity in your disablement and likelihood of you not recovering. 
Own vs Any OccupationYour TPD cover will typically fall under either an Own Occupation or Any Occupation type. You'll need to meet the definition your policy to be eligible for a claim. Generally:

  • Own Occupation. The policyholder has become disabled and is unlikely to ever return to full-time work in the position of which they are employed.
  • Any Occupation. The policyholder has become disabled and is unlikely to ever be able to engage in any form of regular paid work again for which they may be suited to by education, experience or training.
Waiting periodsThere is usually a minimum waiting period from the time you apply before you can make a claim.
Minimum work history Some insurers require you to meet a minimum level of work before you're eligible.
Loss of independenceFor some policies (e.g. Any Occupation) you're required = to demonstrate an inability to perform a certain number of daily living activities. Daily activities can refer to:

  • Bathing or showering
  • Eating and Drinking
  • Using the toilet
  • Dressing and undressing
Showing ongoing medical careSome policies require you to show ongoing medical care to improve your condition or to prevent further illness.

Understand your insurers criteria

  • It is extremely important for policyholders to be clear on what their policy requires to make a claim as well as the definition their policy falls under to avoid any surprises in the event of disablement

How does criteria vary between insurers?

CriteriaCommon variations between insurers*
The extent of your disablement
  1. You're unlikely to return to any type of work again
  2. You're unlikely to return to your previous role
  3. You lose a limb or suffer a serious injury
Own vs Any Occupation
  • Own Occupation. The definition of "current occupation" will vary e.g If 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 e.g. prosthetics and similar advances in the workplace mean that it can be hard 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 e.g. major head trauma
Minimum work history 
  1. Show 12 months of employment before claim can be made
  2. Full time employment
  3. Not full time but with minimum hours
Loss of independence
  1. You have to show your unable to perform 2-3 daily living activities
  2. Evidence in the form of a diary sometimes required
Showing 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

TPD claims inside and outside of super

How do claims work for TPD inside super?

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

How will my claim be assessed inside super?

In order to receive a TPD benefit from their super fund a member must;

  1. Satisfy all conditions of the fund insurance contract.
  2. Satisfy the permanent incapacity definition as stated under super law.
  3. Satisfy “disability super benefit” definition stipulated under Australian tax law. This will allow the policyholder to claim an additional tax-free portion on the lump sum benefit.
  4. Fund trustee must be satisfied that the insured has met the conditions of the policy and is unable to engage in employment that they have are qualified in by education, training or experience.

How do I make a claim inside superannuation?

  1. Contact Super Fund: Policyholder to contact their super fund after which they will be provided with necessary claim documentation. They will also need to provide additional documentation. This might include;
    • Identification - Birth Certificate, Drivers Licence, Passport
    • Existing medical reports
    • Medical evidence to support claim
  2. Submit Claim: Claimant to sign their claim statement and attach to all necessary documentation. This will then be provided to their Case Manager. A Case Manager provides assistance throughout the claim process, ensuring all of the necessary documentation is received.
  3. Organisation of Claim by Case Manager: Case Manager will assess policyholders claim to determine whether they are eligible to receive a TPD benefit. They will usually contact the claimant's employer to receive a written statement as to why they ceased work.
  4. Claim is Assessed By Insurer: An insurance provider will assess the documentation submitted. In some cases further evidence may be require including;
    • Doctors reports
    • Further medical examination with an independent specialist
    • Further information from the claimant's employer
    • Further information from the claimant
  5. Claim is Assessed by Insurer: The insurance provider will assess the claim and determine if it is;
    • Accepted: Claimant contacted with claim payment options.
    • Declined: Claim is deferred while the provider assesses full extent of disability and its permanency. Claim is denied as the insurer has deemed the claimant has not satisfied the conditions of the policy.
    • Deferred: Claim is deferred while the provider assesses full extent of disability and its permanency.

If the claim is deferred or declined it will be referred to the fund trustee who will review the decision made by the insurance provider on the claimant's behalf.

How do I make a claim (outside of super)?

Claiming standalone TPD Insurance is quite similar to claiming TPD held inside of Super though there are some differences between the two processes. Each claim process may differ depending on the type of claim and the insurance provider though in most cases it follow the following steps.

Steps to make a TPD claim:

  1. Contact the insurers claims team: The claims team will provide the policyholder with the necessary claims form. Your financial adviser may assist you fill out the documents if necessary.
  2. Prepare Necessary Documentation: This will usually include;
    1. Completed claim forms
    2. Medical attendants statement completed by certified medical practitioner giving verification of the illness/injury.
    3. Bank details may be required to allow provider to deposit any benefits into nominated account.
    4. Details of previous health claims may be required.
  3. Submit Claims Documentation: Completed claim documentation to be submitted to insurance provider.

How do TPD claims work for multiple super funds?

It is not uncommon for people to have TPD insurance that has accumulated in multiple funds that have been opened by different employers. It is possible in some circumstances for the policyholder to claim multiple benefits at the same time. However it is important that the claimant carefully checks the conditions of each fund before submitting multiple claims at the same time.

Is there a time limit on superfund claims?

There is no time limit on when an TPD claim can be made for a benefit payment for TPD held within Superannuation. That said, there are time limits placed on when an appeal can be submitted for the 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 making of the trustees decision of which the complaint is related to.

Mental illness, claim denials and complex terms

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

Policyholders should be aware that it can be difficult to prove that they will be unable to return to work again on account of mental illness. The episodic nature of mental illnesses can make it difficult for diagnosis to be formed.

Considerations for TPD claim related to depression and mental health

  • The type of treatment prescribed by practitioner and the regularity of that treatment. This consideration is of particular importance for claims that are late in submission.
  • Benefit payment for a mental health claim may be deferred if it is believed that the permanency and severity of the insureds conditions is unable to determined. This can be prolonged until all treatment options are trialled.
  • Definition of total and permanent disablement in policy. For claims based on disability preventing individual from their own or any occupation as a result of work related stress, an underwriter will assess if they would still be unable to perform their duties at another place of employment or if their duties at their current work were adjusted.

What if my claim gets denied?

In the event that the claim is denied by the Insurance provider, there are certain steps that can be taken to have the decision reviewed.

Appealing your claim

  1. Submit a Complaint to the Insurance Provider. Policyholders should contact the chief underwriter of the insurance companies claim department. It is important to Take the time to set out the complaint to the underwriter in full with evidence to justify request for further review. Policyholders should request that the chief underwriter addresses each issue. The policyholder may be required to receive further medical documentation from their doctor. A more comprehensive report may be needed if the claim is to undergo further review.
  2. Submission of Complaint to the Insurance Providers Internal Dispute Resolution Service. If the policyholder is not satisfied with the response received by the underwriting division they are able to write to the Complaints and Disputes Resolution Manager of the Company. Each insurance provider is required to have this department under standards set by the Australian Securities and Investments Commission.
  3. Submit Complaint to the Financial Ombudsman Service. If the claimant is not pleased with the response from the provider they are able to write to the Financial Ombudsman Service. All claimants will need to undertake the previous steps with the insurance company before contacting the Financial Ombudsman Service.

Why do life insurance claims get disputed?

Type of claim disputePercentage of total claim dispute 
General denial5%
Limitation period2%
Reason not provided for denial1%
Waiting period1%
Approved claim with late or no payment1%
Income protection ceased1%
Sickness vs injury0%
Customer service0%

Duty of Disclosure

It is crucial for anyone looking to take out protection cover that they fully understand their obligations under a “duty of disclosure”. In the event that a claim is made, this is the first document that will be checked against the claim application form. Before applicants enter into an insurance contract for TPD cover, they are required to disclose any relevant information that may be required by the insurance provider to allow them to assess your situation. This is known as the duty of disclosure. This duty of disclosure is legally binding and applicants must disclose any relevant known information to avoid legal consequences for not informing the underwriter of information that may affect the policy. In the event that the applicant has failed to comply all information in their duty of disclosure and the policy is less than three years old, the insurer is within their rights to check the duty of disclosure and terminate the contract. In the event that the insurer finds that the duty of disclosure is fraudulent, they may also 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.

Partial disablement feature

Some insurance providers will provide the option for Partial Disablement where as a result of sickness or injury the policyholder is not totally disabled and is able to work in their own occupation at a reduced capacity. As a result, the insureds monthly income is less than the pre-disability income. This must be certified by an approved medical practitioner.

Benefits may be paid out if you meet any of these two definitions

  • Hours Based Partial Disablement: Benefit paid if policyholder has returned to work following being partially disabled for entire duration of waiting period and is able to perform duties in their occupation for defined number of hours, is earning less than their pre-disability income and is under medical care.
  • Duties Based Definition: Benefit paid after policyholder has returned to work following being totally disabled and is not capable of performing the duties essential in producing their income and is forced to earn less than their pre-disability income.

This benefit is determined using the following formula:

(Pre-disability income - post-disability income) / (pre-disability income x monthly benefit) Some policies will provide this partial payment under certain defined conditions suffered by the policyholder. This may include the permanent loss of the use of;

  • One arm, or
  • One leg, or
  • Sight in one eye

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William Eve

Will is a personal finance writer for 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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10 Responses to How To Make A Successful TPD Insurance Claim

    Default Gravatar
    lana | December 29, 2016

    My Tpd claim thru my super has been approved my 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

      Richard | January 4, 2017

      Hi Iana,

      Thanks for getting in touch. 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,

    Default Gravatar
    Sean | October 19, 2016


    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
      v | November 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?

    Default Gravatar
    John | September 28, 2016

    Are there any regulations on how long a claim should take? I have supplied all documents but have been told the claim can take up to 18 months to decide?


      Maurice | September 29, 2016

      Hi John,

      If you’ve provided all necessary documentation and you feel as though your insurer is not processing your claim in promptly manner, then it’s a good idea to:
      1) Go through your insurers dispute resolution service to escalate the matter
      2) Get in touch with the financial ombudsman service if you can’t resolve it internally

      You may find this link useful:

      I hope this helps,


    Default Gravatar
    Christopher | September 19, 2016

    I had a hip and knee replacement with complications, I have
    submitted a claim through my superfund. Now the insurance company contacted my surgeon for more medical information
    The surgeon said he has not got time to do another detailed report
    Where do I go now,does the surgeon have to do
    another medical report when asked by the insurance company.

      Maurice | September 20, 2016

      Hi Christopher,

      Thanks for your question.

      Insurers will typically ask for additional medical information when assessing claims. If you’re unable to get a report from you surgeon, you may wish to seek out an additional/second medical professional who is able to provide a medical report for your insurer.

      If you have provided all necessary information and are still are unable to get to a resolution through your insurer, it’s best to get in touch with the financial ombudsman.

      Best of luck,


    Default Gravatar
    | August 23, 2016

    I am currently on SCI through my super and my employer has terminated my employment on the basis of unsustainability. I have been on sick leave since 02/01/2016 and I am still unwell. I contacted my insurance company who have advised me I will still continue to get SCI payments for the duration of the 2 year maximum or until I’m well. My insurance was through my staff super with automatic cover. Prior to being ill I was on SCI payments for an unrelated illness and had been so for the previous 2 years which ended 28/01/2016 so that meant I went from one claim for a condition straight into another new claim for the second condition. Due to the 2 years expiring I was no longer able to claim for that condition, however I am still left with an illness that is unrelated to the current illness. Prior to new illness I was on restricted duties and hours and was only working 12 hours a week with medical certificates and was struggling even to work those limited hours because I was on restricted hours my insurance would only cover me for the hours I had worked prior to new illness, therefore I was only entitled to 12 hours for my new illness. I have no prospects of getting work in my usual occupation that I am trained for and having a condition that is not likely to improve I don’t believe I am employable. My question is due to the fact I’m currently receiving SCI payments and will continue to do so up until 2018 if my condition continues will I be able to claim TPD insurance on both or one of conditions that have left me unable to return to my usual occupation that I am qualified by education or training. How long do I have to make a claim for TPD and can I claim while on SCI payments for another illness. What will happen to my SCI I’m currently on if I do apply for TPD on other condition. Very confusing I hope you understood all that . Thank you

      Richard | August 24, 2016

      Hi Alija,

      I’m sorry to hear about your situation. is a comparison service and we are not permitted to provide our users with personalised financial advice. You should contact your super fund to see if you have a TPD component of cover and if you are eligible for a TPD payment.

      Best of luck,

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