Total and Permanent Disability (TPD) is a one-off lump sum payable to individuals who are forced to cease working due to severe illness or injury. Unfortunately, over 15% of TPD claims are rejected. TPD disputes can be difficult, which is why it is important to have an experienced lawyer representing you.
At TPD Compensation Lawyers, we understand all aspects of the claims process. This includes challenging rejected claims so we can get our clients the payout they deserve.
Discover the available options for TPD disputes and get the legal expertise you need. Call TPD Compensation Lawyers at 03 9966 7188 today for a FREE consultation. Our TPD lawyers handle claims on behalf of clients in Melbourne and all of Victoria.
What Percentage of TPD Claims Are Successful?
Research by Insurance Watch found that the rate of acceptance for TPD claims has dipped slightly in recent years. The latest figures show that 83% of Total and Permanent Disability are accepted—a decrease of more than 3% from the year prior.
Why Do TPD Claims Get Rejected?
The most common reason TPD claims are rejected is failing to meet the insurer’s definition of Total and Permanent Disability. Definitions of TPD vary from one insurer to another; some require you not to be able to work in your chosen occupation, whilst others only pay an entitlement if you cannot work in any suitable occupation.
Other reasons commonly cited by superannuation funds and other TPD insurers for rejecting a claim include:
- Filing before the waiting period is over
- Missing evidence of disability
- Insufficient medical documentation
- Discrepancies in the information provided, either in the TPD claim or when the TPD cover was taken out
- Not meeting the insurer’s requirements for work history
- The insurance policy is inactive or cancelled
The insurer will send you a letter explaining why your claim has been rejected. Bring this letter, as well as your full insurance policy, to our lawyers who specialise in TPD claims. They can advise you of your options for overcoming the rejection of your claim, as well as represent you going forward.
What Are My Options for TPD Disputes?
Once you understand why your application was rejected, you and your lawyer can work together to contest the decision. TPD disputes are subject to very tight deadlines (usually 28 days), so there is no time to lose in seeking legal representation.
You have 3 options for disputing the insurance company’s decision:
1. Internal Dispute Resolution
All TPD insurers have an internal dispute resolution (IDR) process where claimants can request that their application be reconsidered. Details of the review process can be found on the letter rejecting your claim.
You may be able to overcome the initial denial of your claim by:
- Submitting additional medical evidence
- Undergoing additional medical assessments and providing reports from appropriate experts
- Addressing other concerns with your application, such as providing strong evidence of how your condition prevents you from working
- Providing other necessary documents, such as financial records, proof of work history, etc.
Furthermore, you can lodge a formal complaint through the IDR process if you believe the initial review of your claim was impacted by issues such as poor communication or unreasonable delays. TPD disputes and complaints are generally handled by a separate department, which typically reviews decisions faster than the case managers who first handled your application.
2. Complaint with the Australian Financial Complaint Authority
The Australian Financial Complaint Authority (AFCA) provides dispute resolution services for life insurance products, including TPD insurance. If going through the insurer’s internal dispute resolution process doesn’t result in a favourable decision, AFCA may be the next place to turn.
AFCA complaints can be filed online, by phone, or via email. Issues the AFCA can consider include:
- Delays in processing your claim
- Providing you with inaccurate or misleading information
- Excessive requests for additional information and evidence
- Wrongful rejection of a TPD application
- Underpayment of a TPD insurance benefit
- Barring a claim on the grounds of pre-existing condition when it isn’t
- Cancellation of a TPD policy without notifying you
- Groundless accusations of fraud
AFCA prioritises efficiency and fairness in resolving disputes. Claims are often fast-tracked if they involve straightforward issues or the complainant is facing financial hardship. This may result in timely resolution and payment of your TPD entitlement.
As a rule, AFCA will try to resolve disputes informally through settlement negotiations or conciliation conferences. With the assistance of a TPD lawyer, you and the insurer may be able to reach an agreement. If the informal methods do not work, an AFCA decision maker will move onto making a final determination. They may provide a preliminary assessment giving the parties one final chance to settle the matter. Otherwise, a binding decision will be issued that may or may not award you compensation.
It is critical to have a TPD lawyer represent you throughout the AFCA complaints process. Your lawyer can help draft the initial complaint, act on your behalf through the various methods of dispute resolution, negotiate a settlement, and explore additional legal options if necessary.
3. Court Proceedings
AFCA determinations are legally binding, particularly on the super funds and insurers. If your TPD dispute results in AFCA finding against you, then your only option is to appeal this decision by starting Court proceedings.
The Court will review both your TPD application and the insurance company’s handling of the claim. In TPD disputes, it falls on the Court to answer two key questions:
- Was the insurer’s decision reasonable, based on the available evidence?
- If the decision was unreasonable, does the claimant actually meet the definition of Total and Permanent Disability?
If the Court finds that the insurance company’s decision was unreasonable based on the evidence, it will then need to decide if you meet the relevant definition of being TPD. This will determine whether you have a viable entitlement claim.
Going to court can be costly, time-consuming, and nerve-wracking. There is also no guarantee of success. For all of these reasons, it is in your best interest to have a specialist lawyer who is well-versed in applicable legislation and case law handle your claim—both the preparation and any court proceedings.
Need Help Navigating TPD Disputes?
TPD Compensation Lawyers provide expert assistance and representation throughout all aspects of TPD claims, including TPD disputes. We are committed to obtaining a payout on your behalf. This might involve appealing the insurer’s decision, lodging a complaint with AFCA, or commencing proceedings in court. Sometimes, we must do all three.
Don’t give up if your TPD application has been rejected. TPD Compensation Lawyers can review the insurer’s reason for denying your claim and fight for a favourable outcome. We serve clients throughout Victoria from our office in Melbourne.
Call 03 9966 7188 today if you are in need of assistance. Your initial consultation is FREE, and our No Win, No Fee agreement guarantees that you pay nothing until we get you an entitlement.