Total Permanent Disability (TPD) insurance exists to protect you in the event of an injury or accident that impacts your ability to earn a living. In a worst-case scenario, the ability to file Total and Permanent Disability (TPD) claims to ensure your financial needs are covered if you’re unable to work can alleviate the stress of a life-changing situation.

What do you do if your TPD Insurance claim is rejected? First, we understand the most common reasons for claim rejections. By doing so, you may find the path to successfully appeal the decision. You have a right to fight back and you should, ideally by allowing a legal professional to fight the battle for you.

Facing Rejection: Common Reasons for Denied TPD Claims

Whether you have TPD Insurance in Super or a private Total Permanent Disability Insurance policy, there are several reasons for claim denials. We cover the most common here.

Severity of Injury

Unfortunately, your insurer could disagree with the extent of your injury or disability and the impact it has on your ability or inability to work. This is where medical records come into play. If one doctor isn’t sufficient, you can get a second opinion to show more evidence.

Pre-existing Conditions

An insurer may reject your claim for full benefits using an eligibility loophole. Essentially, if you have a pre-existing condition, they could deny your claim on the premise that it contributed to your total and permanent disability, thus rendering your policy useless.

Potential for Future Work

Every policy is different. Some policies may only pay out if you are unable to return to work in any capacity, while others payout if you are unable to do your specific job. If the insurer has reason to believe you can find any form of suitable employment, they may deny your claim.

Incomplete Medical Evidence

Submitting complete evidence is vital to a successful claim for permanent disability work cover. If your medical evidence is incomplete, it weakens your case. In some cases, they may reach out and request further documentation. In other cases, they will outright reject your claim.

Appealing the Decision: Your Right to Fight Back

It isn’t over if you have already received a rejection for your TPD claim. Before you exercise your right to appeal the insurance company’s decision, there are things you need to understand.

Time Limits

For the most part, there are no time limits on TPD policies, whether you have Total Permanent Disability in super or privately.

There are time limits when it comes to appeals.

You have 28 days from the date of your rejection to file an appeal. If this appeal fails, you can lodge a complaint with the Australian Financial Complaints Authority (AFCA). Finally, you have six years if you wish to pursue court proceedings over the issue.

Gathering Evidence

This is where a lawyer can assist – all of your medical documentation, diagnostic tests, specialist reports, and any other documents that demonstrate how your disability or injury prevents you from resuming work.

Understanding the Appeal Process

While you can proceed without a lawyer, you should contact a legal professional for help. Look to the rejection letter to understand why your claim was denied and what you can do to bolster your claim. This letter will outline what is required to prove your claim and explain the appeals process.

The first official step is lodging a complaint with the policy provider’s Internal Dispute Resolution (IDR) Department. They have 30 days to respond or 45 if you have TPD in super. If you’re still unsuccessful, you can escalate your complaint to the AFCA.

Building Your Case

A lawyer will go through your TPD policies with a fine-tooth comb to determine which ones you’re eligible to claim against. It could be one or multiple, but regardless, they will build your case to show the required evidence that you meet the eligibility criteria for a successful claim. Claims are often rejected because claimants don’t provide enough information or understand how to highlight their evidence to show they’re eligible. The more evidence you have, the more likely you are to be successful.

The Power of Legal Representation

A lawyer skilled in handling TPD claims understands legal jargon and the ins and outs of the system, providing you with key benefits during the appeals process.

Understanding the Law
Lawyers know the law, and they can take a complicated subject and break it down to show you what you need to prove your case and help you gather the evidence. When the law is involved, you need someone on your side and a lawyer understands the system.

Gathering Evidence
A lawyer knows what evidence will help and where to find it, ensuring your claim is successful the first time. If you already filed and received a rejection, a lawyer can help ensure your appeal is successful.

Negotiating with the Insurer
When you use a lawyer, you don’t need to worry about dealing with the insurer – your lawyer will handle all the negotiations.

Representing You at Hearings
Litigation is the last resort, but, if your claim has to go to court, a lawyer will represent your best interests at hearings.

How AJB Stevens Can Help

As skilled lawyers with expert knowledge in handling the TPD claims and appeal process, we ensure you get the compensation payout you deserve. You’ve been through enough trauma and stress while dealing with a life-changing event. You shouldn’t be dealing with the stress of the appeals process on top of everything else, let us handle the details so you can focus on what matters – you.