Life can be unpredictable, and while you can’t plan for everything, investing in Total Permanent Disability (TPD) Insurance is a wise move if you want to prepare for any outcome. While most Australians have Total Permanent Disability in super, there are also private policies for additional protection. Whether you have TPD Insurance in Super or a private policy, we detail how to maximise your TPD claim, the documentation that will support your case, and the legal strategies that lead to successful claims.
Total Permanent Disability Insurance Claims Defined
If you are permanently disabled or injured, TPD Insurance provides a lump sum payout when you make a claim. Claims should be filed according to your policy; it’s generally directly with the insurer or through the superannuation fund if your policy is in super.
Claimants must understand that the definitions vary from policy to policy. One policy may payout if you cannot return to your job, while others will only pay out if you are unable to return to any kind of work. The former offers more comprehensive cover, allowing you to heal and focus on your future without worrying about retraining in another field.
The key is understanding what your policy provides and the eligibility requirements for a successful claim.
The Legal Framework: Total and Permanent Disability (TPD) Claims
While there isn’t a specific statute governing TPD, there is a legal framework for this type of insurance. Look to contract and superannuation law, including:
Superannuation Supervision Act 1993
This act covers trustee obligations, and the Superannuation Regulations Act 1994 provides additional rules to support SSA-1993.
This act details the trustee’s duties regarding the members’ interests.
The Insurance Contracts Act 1984
This act regulates good faith requirements and insurer behaviour.
In New South Wales, documentation challenges can present an issue. You may face delays in gathering the correct medical documents from hospitals and specialists. So, the quicker you make your requests, the more smoothly your claim will proceed. Additionally, some claimants face delays for specialist appointments, which can put an unnecessary delay on the documentation required for your claim.
The insurer and trustee are obligated to act reasonably and to always operate in good faith.
The Importance of Documentation
Documentation serves as evidence to the claims you’re making in your TPD claim, and it can be the difference between a successful claim and failure.
In addition to employment records that are relevant to proving you are unable to work again, you will also need to produce medical evidence, evidence of your attempts to return to work, and evidence of workplace adjustments or restrictions. Additionally, you should produce statements from treating practitioners, functional capacity assessments, and independent medical examinations. You may be required to provide Centrelink records.
Insurers very rarely meet the claimant in person, so your documentation has to paint a clear picture.
Maximising Your TPD Claim’s Impact: Essential Documentation
Medical Records
In addition to the detailed diagnoses, you will need to present a history of treatment, any specialists’ reports, your long-term restrictions, and prognosis. If relevant, you will need to produce mental health records as well. The more consistent your records are, the more credible your claim is, and the stronger your case.
Treating Physician’s Reports
Often, the most important evidence in a claim, the treating physician’s report, is key. The report should address all of the insurer’s key questions and provide full clarity about the patient’s permanent inability to return to the workplace.
Employment and Workplace Documentation
In addition to your employment contract and employer statements, you will need to present the relevant job descriptions, a record of your duties in the workplace and your responsibilities, and evidence that you attempted to return to work.
Superannuation Documents and Insurance Policy
Always read through your policy documentation, whether you hold a private policy or your Permanent Disability Work Cover is in super. Note the wording of the policy, the way it defines disability, the waiting periods before you can claim, the time limits, and exclusions. Don’t wait until you need to claim to get to grips with what your policy provides in the event of a total and permanent disability.
Independent Reviews & Functional Assessments
Functional assessments are used to evaluate someone’s ability to carry out everyday activities as well as more complex tasks. Independent reviews can be requested by legal entities, employers, or insurance companies to get an expert opinion separate from the treating physician.
Functional Capacity Evaluations
This comprehensive assessment is focused on the claimant’s physical or cognitive abilities, and in some cases, both. This includes a review of medical records, a detailed interview, and functional tests related to work. It’s generally used to assess a claimant’s fitness to return to work.
Neuropsychological Assessments
This in-depth assessment is specifically focused on testing cognitive function, including attention, executive function, language, memory, and problem-solving. This is generally requested after a stroke, brain injury, or dementia. This can aid in a differential diagnosis, but is primarily used to determine the extent of the claimant’s cognitive impairment.
Pain Specialist Reports
A medical specialist evaluates chronic pain conditions and will evaluate behavioural, biomedical, and psychosocial factors to highlight underlying causes and document how the pain is impacting the individual’s life.
Personal Statements
The more detailed your written personal statement is, the more likely your claim is to be successful. It isn’t about exaggerating your illness; stick to the facts, but you can strike a personal tone. Detail the impact of your disability, what limitations it has placed on your daily life, discuss your treatment history, and your barriers to returning to work. They won’t meet you, so you have to communicate clearly.
Common Mistakes That Doom Claims to Failure
If you’re worried about slipping up and dooming your claim to failure, avoid the most common pitfalls listed below.
- Contradictory reports
- Delayed response to an insurer’s request
- Incomplete forms
- Inconsistent statements from the claimant about capacity
- Failure to read and understand the policy definitions
- Outdated (or missing) medical records
- The treating physician does not sufficiently understand the TPD definitions
The Legal Strategies To Strengthen Your Claim
Working with a lawyer to complete your claim can help you prevent the most common pitfalls and also help craft a sound legal strategy to strengthen your claim.
Policy Definitions
A lawyer will locate all the TPD policies in your name and identify the most favourable interpretation to ensure a successful claim. Policies do vary widely, and you may find the older policies still allow you to claim against more than one policy. A lawyer will help you identify every option.
Evidence Preparation
A lawyer will help prepare the evidence to ensure it aligns with the insurer’s criteria, they know which questions the insurer will focus on, and they will help you gather targeted evidence to address those questions. Your lawyer will also assist your medical practitioners with language and formatting.
Insurer Requests & Deadlines
The best way to avoid missing a deadline is to ensure your claim is completed properly. Likewise, you can prevent delays by providing an abundance of evidence from the start, rather than leaving insurers to chase you or your lawyer for additional documentation.
Appealing a Decision
In addition to external dispute resolution, your lawyer can advise whether a simple appeal will solve the issue or where further legal action may be likely.
Connecting the Medication Limitations to Vocational Restrictions
Since lawyers understand policies and definitions, they will help clarify why you cannot work by connecting the medical evidence you have to practical work limitations.
The Value of Early Legal Advice
Speaking to a lawyer as soon as possible will improve the likelihood that your claim succeeds. Not only will working with a lawyer reduce the risk of errors, but it will also ensure you gather the correct documentation promptly. A lawyer will support you through the process and protect you from unreasonable (or unfair) insurer conduct and behaviour to secure the claim you deserve.
How AJB Stevens Can Support You Through Your TPD Claim
If you have experienced a permanent disability, injury, or illness and need help with the TPD claims process, AJB Stevens can help. Our team will help you understand the complex TPD definitions, assist in the documentation and evidence gathering process, and liaise with medical specialists on your behalf.
The AJB Stevens team is skilled in challenging TPD Claim rejections, but we also offer supportive guidance throughout and clear communication.
