Making a claim on TPD insurance policy

Hello, my name is Gavin Hanrahan. I am a litigation solicitor in today on going to talk about total and permanent disability insurance commonly referred to as TPD insurance.

In broad terms, there are two types of TPD insurance cover.

Own occupation, and Any occupation.

If you take out an Own occupation policy, it kicks in when you’re unable to work again in your nominated Own occupation.

If you take out an Any occupation policy, it only kicks in when you are unable to ever work again in any job suited to you given your education, training or experience.

An Own occupation policy will cost you more, but is easier to claim on than Any occupation.

How do you claim?

Here’s a step-by-step process to follow:

1. First of all, contact the insurer and request a TPD claim form. The form will look something like this.

2. The first few pages of these forms are usually about your personal details to be filled in by you. Such things as name, address, illness or injury, occupation, etc.

3. The next part of the form is usually a medical certificate or report to be completed by your doctor. You have your doctor complete that form.

4. Once the form is completed, send the form back to the insurer.

The insurer probably will arrange for you to be assessed by one of its doctors. The insurer will write to you to let you know the details of the assessment. If the date or time doesn’t suit you, just let the insurer know, and I’m confident they will make fresh arrangements.

Once the insurer receives the report from its Doctor, it should decide your claim soon thereafter.

If it accepts your claim, then all is good.

If it doesn’t, AND IT SHOULD HAVE based on the evidence, then it has breached its contract with you, entitling you to commence legal proceedings against the insurer.

Sometimes the insurer won’t get back to you in a reasonable time, say 3 months, and if it had IT SHOULD HAVE accepted your cliaim, then it has breached its contract with you, as this also entitles you to commence legal proceedings against the insurer.

What are your legal avenues for pursuing the insurer?

If your TPD is within your superannuation fund, then there are two: Court and the Australian Financial Complaints Authority (AFCA).

If your TPD is not within your superannuation fund, then court is the only Option.

If AFCA is an option for you, I recommend you lodge a complaint with AFCA and it will determine your complaint. The complaint must be lodged within two years of the insurer’s determination. Although you may benefit from legal representation before AFCA, it is not a requirement, and if you stuff up your complaint it’s not the end of the world, because you still have the court option.

The AFCA determination binds the insurer, but not you. If you are dissatisfied with the AFCA determination, you can choose the Court option.

That covers off on the first option, and remember its only available to you if you TPD is within your superannuation.

Just a reminder, if your TPD is not within your superannuation, then court is your only option.

The court option requires legal proceedings to commence within six years of the insurer’s determination. Just like with an AFCA complaint, you can represent yourself in court; however, I do not recommend that anyone do so. The Court is bound by the rules of evidence, which are complex and difficult to navigate, but is the bread-and-butter of litigation lawyers.

What sort of evidence will you need to establish your claim?

As in most injury or illness-related legal proceedings, the principal evidence supporting your claim will be your testimony as to your circumstances, reports and clinical notes from your treating medical practitioners and reports from any independent medical specialist engaged to provide an opinion about your disability and incapacity for work.