How to maximise your chances of a successful TPD claim

Total and Permanent Disability (TPD) insurance provides financial assistance if you're unable to work due to illness or injury. However, the TPD claims process can be complex and stressful, especially when you're already facing health challenges. This blog provides practical tips to help you maximise your chances of successfully applying for a TPD benefit.

TPD insurance is a very important benefit which is accessible to most Australians who have a superannuation account. Because Australia has laws which provide for compulsory contributions by employers to workers’ superannuation, it is very likely that you have the ability to apply for a TPD benefit payment.

This blog is more detail about the claim’s process, but you can read a general overview of TPD claims here.

What is TPD insurance?

TPD insurance is a type of cover that pays a lump sum benefit if you are no longer able to work in your usual occupation or any other job that you're qualified for due to a serious illness or injury. 

The exact definition of "total and permanent disability" can vary between insurance policies, so it’s essential to get an understanding of how your particular super policy defines ‘Total and Permanent Disability’, before proceeding with a claim.

Notably, if you have more than one super account, you may have disability insurance (like TPD and income protection) in multiple funds. In most circumstances, you will be able to make multiple successful TPD claims. Again, the definitions of each individual policy will be crucial.

Some types of TPD insurance policies

"Own occupation" cover

This applies if you cannot work in the specific job you were doing before your illness or injury. This type of policy is more expensive and is generally only available outside of superannuation.

"Any occupation" cover

This applies if you're unable to work in any job that you are reasonably qualified for by education, training, or experience. This is the standard policy type offered by most superannuation funds.

Being aware of the differences between these policies is very important, as it affects your eligibility to claim. If you have "any occupation" cover, your claim may be denied if the insurer believes you can work in another capacity, even if it’s not your usual job/occupation.

Tips for maximising your TPD claim success

It’s important to have a general understanding of the specific eligibility criteria, waiting periods, and definitions of "disability" under your policy.

The vast majority of superannuation TPD policies are "any occupation", and this will influence the type of evidence you will need to maximise your prospects of being successful with your TPD benefit application. By familiarising yourself with your policy, you can better prepare your documentation and avoid potential pitfalls down the track.

Gather comprehensive medical evidence to support your TPD claim

One of the most critical aspects of a successful TPD claim is strong medical evidence. The insurer will want detailed information about your condition, so consider the following.

1. 1. Where possible, obtain medical reports from specialists, but definitely obtain evidence from your general practitioner who is able to note your diagnosis, treatment history, prognosis, and the impact of your injury or illness on your ability to work.
   2. Include test results, imaging reports (like MRIs or X-rays), and any rehabilitation records.
   3. Ensure that your doctors explicitly state that your condition prevents you from returning to work in any capacity related to your skills, training, or experience.

A well-documented medical file demonstrating that your condition meets the policy’s definition of “total and permanent disability” can significantly improve your chances of approval.

Get help from your current and/or former employers

Your employer’s input can be a valuable part of your TPD claim, especially if they can confirm that your condition prevents you from performing your usual job duties. Request a letter from your employer detailing:

1. 1. your previous job role and responsibilities;
   2. how your condition affected your ability to perform those duties;
   3. confirmation that no suitable alternative employment was available within the organisation.

This documentation can provide additional evidence to strengthen your TPD claim.

Keep detailed records of your condition and symptoms

It is recommended that you begin to keep a personal diary of your symptoms, pain levels, how your condition affects your daily life, and any other information that might go to support your claim. Disability insurers often look for consistency between your medical records and your personal account, so keeping detailed, honest, and regular records can strengthen your application.

Complete all forms accurately

The insurer will scrutinise every detail in your TPD application. Errors, inconsistencies, or omissions in your forms can delay or jeopardise your claim. 

To avoid this, take your time when completing your claim forms. Double-check that all information is accurate, particularly regarding your employment history, medical condition, how your injury/condition is impacting your life, and your ability to work. 

Inaccurate or incomplete forms are one of the most common reasons for claim rejections.

Getting legal assistance from a TPD lawyer at the outset of your claim will mean you can be confident that you are getting things right from the very beginning.

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Common pitfalls to avoid when applying for TPD benefits

Even if you follow all the right steps, some common mistakes can hinder your chances of a successful TPD claim. Here are a few to be aware of.

1. Delaying lodging your TPD claim

There are strict time limits for lodging a TPD claim, which can vary depending on your superannuation fund’s rules. Delaying your application can make it harder to gather the necessary evidence and may lead to a rejection based on late submission. Start the process as soon as you become aware of your injury or illness.

2. Inconsistent medical records

Insurers will review your medical history in detail to ensure that your condition aligns with your claim. Any inconsistencies, such as conflicting medical opinions or gaps in your treatment history, can raise red flags. Make sure your healthcare providers are consistent in documenting your condition and its impact on your ability to work.

3. Failing to meet the insurer's definition of "total and permanent disability"

The definition of "total and permanent disability" can be quite restrictive. Insurers often require proof that your condition is unlikely to improve to the point where you could return to any form of work. If your medical records suggest that there’s a chance of recovery, your claim may be denied.

What to do if your TPD claim is denied

If your TPD claim is denied, don't lose hope. You can appeal the decision. This is the definitely a point at which you should seek legal advice and assistance. Below are some steps to take if your TPD claim is denied and your lawyer can assist with these to ensure the success of any appeal.

1. Review the insurer’s decision

If your TPD is rejected, carefully review the letter explaining why your claim was denied. Often, claims are denied due to insufficient evidence (including medical evidence), missing documents, or due to a technicality. Understanding the reason can help you strengthen your case on appeal.

2. Gather additional evidence

If your claim was denied due to lack of evidence, consult with your doctors to obtain more detailed reports. Additional medical assessments, functional capacity evaluations, or statements from specialists can provide the necessary proof to support your appeal.

3. Lodge an appeal

Most superannuation funds have an internal review process for denied TPD claims. An internal review is the first step that must be undertaken. If your internal appeal is unsuccessful, you can escalate the matter to the Australian Financial Complaints Authority (AFCA), which offers a free dispute resolution service.

4. Consider legal action

If your appeals fail, consult with a TPD lawyer to explore the possibility of taking legal action. This should be a last resort, as litigation can be costly and time-consuming. However, with professional legal support, you may be able to reach a settlement without going to court.

Seek legal advice from a TPD lawyer as soon as possible

Applying for a TPD benefit through your superannuation fund can be a challenging and time-consuming process, but careful preparation can significantly increase your chances of success. By thoroughly understanding your policy, gathering comprehensive medical evidence, and seeking legal advice at the start of the process, you can significantly improve your prospects of a successful claim.