Total and Permanent Disability (TPD) insurance provides a financial safety net if you become permanently disabled and can no longer work. Making a successful TPD claim can be a complex process, however – so we’ve collected the key information points here and provided tips on how to present strong evidence to support your claim.
Key Factors Insurers Consider When Assessing TPD Claims
Knowing that each case is different, an insurer will consider several factors when assessing your TPD claim. Let’s take a look at the different considerations.
Definition of TPD in Your Policy
The definition of TPD can vary between policies. Generally, there are two main types of definitions:
- Any Occupation: You are unable to work in any job suited to your education, training, or experience.
- Own Occupation: You are unable to work in your specific occupation.
Understanding the definition of your policy is crucial as it determines the criteria you need to meet to make a successful claim.
Learn more about this: Own Occupation' vs. 'Any Occupation': Understanding Your TPD Policy Definition
Medical Evidence
Medical evidence is a critical component of a TPD claim. Insurers will require detailed medical reports from your treating doctors and specialists. These reports should outline the nature and extent of your disability, your treatment history, and your prognosis. The evidence must demonstrate that your condition is permanent and prevents you from working as defined in your policy.
Work Capacity
Your capacity to work is a significant factor in TPD assessments. Insurers will evaluate whether you can perform any work suited to your education, training, or experience. This assessment may include reviewing your employment history, skills, and qualifications. If your policy uses the "own occupation" definition, the focus will be on whether you can perform your specific job.
Waiting Period
Most TPD policies have a waiting period, typically ranging from three to six months, during which you must be continuously unable to work. This period allows your condition to stabilise and the full extent of your disability to be assessed. Insurers will check if you meet this requirement before processing your claim.
Age and Employment Status
Your age and employment status at the time of your disability are also considered. Some policies have age limits, and you must have been employed or actively seeking employment when you became disabled. Insurers will review your employment records to ensure you meet these criteria.
Consistency of Information
Insurers will scrutinise the consistency of the information provided in your claim. Any discrepancies between your medical reports, employment history, and personal statements can raise red flags and potentially lead to a claim denial. Ensuring all information is accurate and consistent is vital.
Insurer-Appointed Doctors vs Independent Assessments
As part of the assessment process, your insurer is likely to arrange for you to be examined by a doctor of their choosing. This doctor is selected and paid by the insurer.
These examinations are sometimes called Independent Medical Examinations (IMEs), but the name can be misleading. After all, this doctor is appointed by the insurer, paid by the insurer, and the insurer is looking for reasons to reduce or deny your claim. The assessment is not a neutral second opinion.
While this does not mean every insurer-appointed doctor will provide an unfair report, it is important to understand the relationship between the doctor and the insurer before attending your assessment.
What can I do to get the fairest outcome?
A TPD lawyer can arrange for you to be assessed by a genuinely independent doctor. This means a medical professional who has no relationship with your insurer and no financial incentive to minimise your condition.
The independent report provides a balanced, evidence-based view of your injury or illness and how it affects your ability to work. If the insurer's doctor reaches a different conclusion, your lawyer can challenge that finding using the independent evidence.
Having both reports on file means the insurer cannot rely on a single assessment that may understate your condition.
'While insurer-appointed doctors play an important role in the claims process, we may also arrange an independent medical assessment. This helps ensure that all relevant medical evidence is considered and that a balanced view is presented.'
Claims That Are Decided Before They're Properly Reviewed
Claimants often feel like their case has been decided without the evidence being reviewed in-depth. In one such case, a woman was told by the claims handler that her claim was going to be denied before all her medical evidence had even been gathered.
This is a deeply concerning issue. You are entitled to a fair and thorough assessment of your claim. The insurer is required to consider all relevant evidence before reaching a decision, not just the evidence that supports their preferred outcome.
Red flags to watch for
- The claims handler (the insurer) tells you the likely outcome before all your evidence has been submitted
- Your medical reports are dismissed or downplayed without clear reasons
- The insurer requests only specific types of evidence that may not fully represent your condition
- Decisions are communicated informally (by phone) without a written explanation
What to do if this happens
If you feel the insurer has already made up their mind before looking at your evidence, you have options. Thankfully, there are formal processes to challenge decisions that are not made properly.
A TPD lawyer can intervene early to ensure the insurer follows the correct assessment process and considers all relevant material before making a decision.
'If you feel the insurer has already made up their mind before considering your evidence, it may be appropriate to question whether the decision-making process has been fair. Everyone is entitled to a fair assessment, and there are ways to challenge decisions that may not have been made with your best interests at heart.'
Delays and Repeated Requests for Information
Some insurers take months to respond to claims or repeatedly request additional information that has already been provided. While some delays are genuine (complex claims do take time to assess), others may be deliberate.
Under the Life Insurance Code of Practice, insurers are expected to make decisions within specific timeframes after receiving all the required information.
Signs that a delay may not be genuine
- You have provided all the requested documents, but have received no update for months
- The insurer asks for information you have already sent
- Each time you provide something, a new request follows with no clear explanation of why
- Phone calls and emails go unanswered or are returned weeks later
Why this matters
Delays cost claimants money. While the insurer sits on your claim, you may be without income, struggling to pay for treatment, or watching your savings disappear. Yes, some delays are expected, but there are limits.
If your claim has stalled, a TPD lawyer can contact the insurer directly, identify what is genuinely outstanding, and push the process forward.
'While some delays are unavoidable, if your claim has been ongoing for several months without progress, or you are repeatedly asked for information you have already provided, it may be worth seeking advice.'
Tips for Providing Strong Evidence to Support Your TPD Claim
The more time and effort you put into collecting evidence and presenting a strong case, the better you will position yourself to receive financial support. Here are a few steps you can take to provide solid evidence.
1. Gather Comprehensive Medical Evidence
- Obtain detailed medical reports from all treating doctors and specialists.
- Include information about your diagnosis, treatment history, and prognosis.
- Provide evidence of any ongoing treatment and rehabilitation efforts.
2. Document Your Work History
- Provide a detailed resume outlining your employment history, skills, and qualifications.
- Include statements from previous employers about your work performance and reasons for leaving.
- Ensure the information is accurate and does not overstate your abilities, as this can lead to incorrect conclusions by the insurer.
3. Maintain Consistent Records
- Keep all documentation organised and ensure consistency across all forms and reports.
- Double-check all information for accuracy before submitting your claim.
4. Seek Professional Medical Opinions
- Consider obtaining an independent medical assessment to support your claim.
- Ensure the medical opinions align with the definition of TPD in your policy.
5. Follow Up Regularly
- Stay in regular contact with your insurer to check the status of your claim.
- Promptly provide any additional information or documentation requested by the insurer.
Staggered Payouts for Serious Conditions
For certain terminal or degenerative conditions, such as kidney failure, heart failure, or some cancers, some insurers structure payouts in instalments rather than providing a single lump sum. This is sometimes called a staged benefit or instalment benefit.
At each stage, you may be required to undergo further medical reviews to confirm your condition has not improved.
How this affects claimants
This approach extends the claims process significantly. Rather than receiving your payments and using them to manage your situation, you may spend years proving that you meet the requirements for a condition.
One claimant described the frustration of the process, explaining that the insurer structured the payout so that they had to keep providing medical evidence at regular intervals over several years, despite having what was clearly a permanent impairment.
What a lawyer does in this situation
A TPD lawyer can review the terms of your policy to determine whether a staged payout is permitted under the wording of your cover. In some cases, the insurer may be required to pay the full benefit upfront.
Where staged payouts do apply, a lawyer manages each stage on your behalf, ensuring the medical evidence is prepared properly and the insurer meets its obligations from one step to the next.
‘For some serious conditions, insurers pay in stages rather than a single lump sum. This means ongoing medical reviews over years. Having a lawyer manage this process can reduce the claimant’s stress and ensures each stage is handled in a way so that the insurer meets their legal obligations.’
How a TPD Lawyer Can Help
Navigating the TPD claims process can be daunting, and even a small mistake can jeopardise your claim. Engaging a TPD lawyer can significantly increase your chances of a successful outcome. Here’s how a TPD lawyer can assist:
Expert Guidance
A TPD lawyer has in-depth knowledge of insurance policies and the claims process. They can help you understand the specific requirements of your policy and guide you through each step of the claims process.
Preparing and Reviewing Documentation
Professional lawyers can help you gather and prepare all necessary documentation, ensuring it is complete and accurate. They can also review your medical evidence and employment records to ensure they meet the insurer’s requirements.
Communicating with Insurers
Dealing with insurers can be challenging. A TPD lawyer can handle all communications with the insurer on your behalf, ensuring that your claim is presented in the best possible light. They can also follow up with the insurer to prevent unnecessary delays.
Challenging Denied Claims
If your claim is denied, a TPD lawyer can help you understand the reasons for the denial and advise you on the best course of action. They can assist with lodging an appeal or taking legal action if necessary.
Note: It is much harder to appeal an already denied claim than to get a claim accepted on its first go. So, while it can seem like a good strategy to attempt a claim yourself first without legal assistance, this can end up being costly if the claim is rejected.
Maximising Your Entitlement
A TPD lawyer will work to ensure you receive the maximum benefit you are entitled to under your policy. They can help you navigate any complex legal issues and advocate on your behalf to secure a fair outcome.
Why Getting It Right the First Time Matters
If your TPD claim is refused, the insurer's decision becomes the starting point for any challenge. You then need to prove the insurer was wrong, which is a higher bar than simply proving you qualify in the first place.
This is why the initial application matters so much. A well-prepared first submission, with strong medical evidence, detailed work capacity information, and a clear link between your condition and the policy definition, gives you the strongest chance of getting it approved the first time
What happens when claims are self-lodged without proper evidence
People who lodge TPD claims themselves, without legal help, often submit applications that are missing critical evidence. If the medical reports are thin or the evidence does not clearly address the policy definition of ‘total and permanent disability’ (TPD), the claim is refused.
Once that refusal is on the record, any review or appeal starts from this disadvantaged perspective. You are no longer just proving your case. You are proving that the insurer made the wrong call, and the insurer will defend its original decision.
Can the insurer’s verdict be overturned? Absolutely. But it’s definitely a steeper climb to reach the same summit. Getting the application right from the start avoids this entirely.
‘It's much harder to challenge a refused claim than to get it approved the first time. Once the insurer says no, you're not just proving your case, you're proving they were wrong. That's why getting the application right from the start matters so much.’
Next Steps
Making a successful TPD claim requires careful preparation and a thorough understanding of the factors insurers consider. By gathering comprehensive medical evidence, documenting your work history, and maintaining consistent records, you can strengthen your claim.
Engaging a TPD lawyer can provide expert guidance and support, increasing your chances of a successful outcome. If you are considering making a TPD claim, seeking legal advice early in the process can help ensure you receive the benefits you are entitled to. Smith’s Lawyers offer free initial advice and all claims are 100% risk-free with our industry leading No Win, No Fee, No Catch promise.
