If you have applied for a Total and Permanent Disability (TPD) or disability pension and your claim has been rejected, there are a number of reasons why this may have occurred..
The most common reason for a TPD or disability pension claim to be rejected is that the person does not meet the definition of ‘totally and permanently disabled’ as set out in the relevant Insurance Guide, Trust Deed or Product Disclosure Statement.
However, there are many reasons why your claim may have been denied and understanding the reason will allow enable you to best decide your next steps.
Reasons Your Claim May Be Rejected
Other reasons for a claim to be rejected can include:
– The person has not provided enough evidence to support their claim
– The person has not been assessed by an independent medical practitioner
– The person has not been assessed by the relevant government authority
– The person’s injuries are not considered to be permanent
– The person’s injuries are not considered to be total
TPD Insurance policies and Disability Pensions have numerous criteria that are constantly changing. As a result, it is generally best to speak with an advocate who can provide you with advice regarding what is required for you to claim.
You Missed The TPD Claim Window
Most TPD Insurance policies are subject to the legislated 6 year time limit when lodging a claim. You will typically have up to 6 years from the time you met all elgibility criteria to lodge a TPD claim. What is often misunderstood is that your policy does not actually have to be in force when you go to lodge a claim, it generally just needs to have been in force at the time of you meeting all of the eligibility criteria.
Your Situation Does Not Fit The TPD Insurance Claim Classification
As touched on earlier, in order to qualify for a TPD or disability pension, a person must usually be unable to work in any capacity for a period of at least 6 months. This includes being unable to work in their usual occupation, any other occupation or to undertake any form of gainful employment.
In addition, a person must usually be assessed by at least one specialist medical practitioner as being unlikely to ever return to work in any capacity in order for their TPD or disability pension claim to be successful. The requirement relating to your capacity to return to work or performing your activities of daily living vary significantly between policies and there is no rule of thumb as to what is required.
You Did Not Fit The TPD And Disability Pension Criteria
There are many reasons why you may not meet the criteria to claim on a TPD Insurance policy. These reasons can include the following:
Your Age – your policy may have expired or the definition of disability (the criteria against which you are assessed) may change as you get older.
Your Occupation – Some products will have a definition of disability that changes based on the ‘riskiness’ of your occupation. For example, you may find that your policy works differently should you be a white collar worker vs a blue collar worker.
You were not at work when your policy started – Some products and super funds require you to be engaged in active employment (subject to hours worked and other criteria) in order for your policy to cover you based on your ability to work.
You do not meet a condition of release from super – Superannuation withdrawals are bound by legislation that is distinct from insurance legislation. The mechanics of a disability insurance claim through super are such that both the insurer and the super trustee need to sign off on the claim payment before it can be released to a member. As the conditions of release from super may vary from the policy itself, it is crucial that you assess the criteria of both your fund and your policy when lodging a claim. More information on conditions of release from super can be found here.
Evidence Has Been Found To Dispute Your Claim
If the insurer has reason to believe that you are not as disabled as you claim to be, they may investigate your claim further. This can include asking for additional medical evidence or surveillance of your activities.
If the insurer finds evidence to disprove your claim, your claim may be rejected.
You Failed To Cooperate With The Insurance Company
If you do not cooperate with the insurance company during the claims process, your claim may be rejected
What To Do If Your TPD Claim Is Rejected
If you have been rejected for a TPD claim, you do have options available to you. You can either:
– Appeal the decision
– Negotiate with the insurer
– Take legal action
Appealing The Decision
If you wish to appeal the decision, you will need to do so within the specified time frame. This will generally be within 21 days of receiving the rejection letter.
When appealing the decision, you will need to provide evidence to support your claim. This evidence can include medical reports, employment records and character references.
It is important to note that there is no guarantee that your appeal will be successful.
Negotiating With The Insurer
Another option available to you is to negotiate with the insurer. This can be done either directly or through a third party, such as a solicitor or claims advocate such as a financial advisor. Disputing a claim with an insurer yourself can be incredibly daunting and a third party expert may well be able to communicate with a fund or insurer in a more effective manner than you are.
Taking Legal Action
The final option available to you is to take legal action. This is not something that should be entered into lightly, and you should speak with a solicitor about your options before taking this step.
General Advice Disclaimer
General advice warning: The advice provided is general advice only and in preparing it we did not take into account your investment objectives, financial situation or particular needs. Before making an investment decision on the basis of this advice, you should consider how appropriate the advice is to your particular investment needs, and objectives. You should also consider the relevant Product Disclosure Statement before making any decision relating to a financial product.
