When you’re injured or sick and unable to work, if you have TPD insurance then you may be eligible for a TPD claim.
It’s important to determine what TPD insurance, if any, that you have. As TPD Lawyers, we often see people who have large TPD insurance policies they didn’t even know they even had!
Once it is determined you have a policy, here are 7 things you should consider in the claims process:
1. Begin by working out the definition of TPD that needs to be satisfied
TPD stands for ‘Totally and Permanently Disabled’. The interpretation of the definition can differ significantly across trust deeds and insurance policies. It is advisable to have a TPD Lawyer review the trust deeds and policies of insurance to determine your eligibility as well as the precise pre-conditions that need to be met. For instance, TPD definitions could include ‘Own’ or ‘Any’ occupation clauses.
An ‘Any’ occupation TPD policy means that a claimant would need to be declared unfit to perform any occupation which may be suited to them by virtue of their education, training or experience. It is not enough to prove that you simply could not perform your own occupation.
An ‘own’ occupation definition is far easier to satisfy as you would only need to prove that you are likely to be permanently unfit for your own occupation. Courts have determined what insurers are permitted to take into account when determining claims regarding the various types of policies.
A TPD lawyer can help you understand your policy type and the different components of the varying definition. If you believe you satisfy the definition under your policy, then you can begin to obtain the evidence that proves you satisfy the definition.
2. The Claim Form
Most claims processes start with an initial claim form from the insurer. As TPD lawyers, we come across most of the claim forms. Your claim form is crucial for an insurer to make a well-informed and timely determination. They all require different information. It is important to understand why certain information is being requested. If you are too brief with answers, it may be difficult for an insurer to make a determination as to your claim as they may require additional information on matters. A claim form can be confusing and overwhelming, which is one of the many reasons why we recommend seeking advice from a TPD lawyer. Generally a TPD lawyer will be familiar with the form, and will understand why the insurer requires the information they are requesting. Not only will a TPG lawyer be able to guide you through the process, but they also have a keen understanding of how to best respond to each item on the form, optimising your results. One needs to keep in mind, much of the information required is to determine your pre-disability employment and whether you are fit for it – (or something else which you may have the adequate skills for (in an ‘any’ occupation test). For instance, some insurers request that claimants provide a copy of a resume outlining pre-disability employment. One issue with simply providing an old resume is that, in our experience, we have found that people often ‘talk themselves up’ in a resume, perhaps somewhat over stating their pre-disability experience. This could foreseeably lead an insurer to draw erroneous or inaccurate conclusions about a pre-injury capacity. It is important to therefore ensure the insurer has accurate information by which to make a decision. It is also important not to feel ‘caged’ or ‘boxed in’ by the questions in a claim form, for instance, if a claim form gives the option of ‘yes’ or ‘no’ but the answer is not adequately reflected in either of those options, then you should make this clear in the form. A TPD lawyer can help you navigate the process, ensure the information provided in the claim form is accurate and give your claim the best chance of succeeding.
3. Medical Evidence
A key part of your claim’s success is providing appropriate medical evidence in support of your claim. This can often be a complicated, multi-stage process and it’s vital to obtain the full and correct information from your doctor. A TPD Lawyer will help you navigate this process and instruct doctors on your behalf. As TPD Lawyers have experience in appropriately instructing doctors so that they understand exactly what kind of information is being requested. When a doctor is asked to complete a medical certificate for a claim form – or alternatively, provide a report – they should be provided with the relevant definition of TPD and asked to comment in relation to it so far as their expertise allows. In some cases, we may ask for the Doctor to provide a more comprehensive report answering various questions, and perhaps providing opinion in relation to evidence that needs to be put before them. It is often the case that more medical records and reports will be required during the claims process, and obtaining reports from multiple treating practitioners may be needed. With TPD claims, it can be the case that other illnesses/injuries/disabilities that you have had prior to your main illness are relevant to your claim.
Many factors can be taken into account when determining whether you meet the TPD definition – not just a primary injury or illness which has caused you to go off work. For instance, if you had a bad ankle – but was able to work, and then hurt your neck badly, becoming unable to go to work, it would be helpful to make sure that the insurer has the full story. Your prior injury may be relevant when determining why you cannot work in other suggested professions where your neck injury alone would not prevent you working. A TPD lawyer can help you ensure certain things like this are included.
4. Providing Sufficient Evidence
It is important to provide enough evidence so that the insurer can determine that you meet their claims assessment criteria. This may, in some circumstances, mean providing evidence outside the scope of that which is requested. For instance, your TPD Lawyer may wish to put on a statement of evidence from you so that the insurer can understand certain facets of the claim. The statement may deal with various pre-disability employment information, and reasons why you may be unsuited to specific roles, that at face value, you may appear to be fit for. Your TPD lawyer may want to put on treating doctors evidence, documents from your employer or and perhaps even Medicolegal evidence.
5. Chasing the Insurer
Once your form is submitted to the insurer, it’s important to chase them until a decision is made. In our experience as TPD Lawyers, we’ve found that insurance companies will often sit on the claim without response for long periods of time. It is extremely frustrating when the insurer delays making a decision and waits a long period of time between communication, but this is particularly so when they require a further piece of evidence. It’s important to make sure that the insurer acts within reasonable time frames. Otherwise, claims can be unnecessarily drawn out and lose momentum. Delays may cause your claim to meet other obstacles such as landing in the hands of new claims officers who aren’t familiar with the case, causing further delay and frustration.
6. Sometimes, don’t take ‘no’ for an answer
Don’t lose hope if your insurer denies your claim the first time. It does not mean that it is the end of the matter. The insurer could deny the claim at first instance for a number of reasons. Usually, the insurer will provide reasons for their denial. A TPD lawyer can then advise as to the best way forward. It may be that further evidence is required, and upon the provision of this further evidence, the insurer can be asked to redetermine the claim. It may be that the insurer has made the determination based on reasoning that you disagree with, and submissions can be provided by your TPD lawyer outlining those arguments and requesting a review. Sometimes your TPD lawyer needs to consider previous decisions of the Courts to help determine if there are similar cases / definitions which have been decided or interpreted by a judge. These cases may be relevant to submissions which are to be put before the insurer in an application for review.
As TPD Lawyers, we understand that it’s often the case that applications for review are often a great way for the claimant to alleviate issues that the insurer may have so that the insurer may determine a claim and provide a positive result.
7. Knowing when it’s time to fight
Unfortunately, sometimes it is the case that even when you think you have a great TPD claim – and you have provided sufficient evidence – the insurer disagrees, and denies your claim. A TPD Lawyer can advise whether you should challenge the insurer’s decision in court. Most of these matters are run in the Supreme Court. It is important to consider what evidence has been provided, as well as legal precedent, when determining whether the claim has reasonable prospects of success before a judge. The decision to commence proceedings should not be taken lightly. Unfortunately, even if your TPD lawyer is acting on a ‘no win no fee’ basis, in the event that you commence proceedings, you run the risk of having to pay the other side’s legal costs if you lose. This can exceed $100,000.00. Nevertheless, sometimes it is necessary to commence court proceedings. It can also be the case that once court proceedings are commenced the insurer will agree to settle your case for the full – or compromised amount. It is important to get a TPD lawyer who has experience with TPD claims to advise you in relation to Court proceedings.
Here at Schofield King Lawyers, we pride ourselves on understanding the TPD claims process and can advise on a TPD claim at any stage. If you’d like assistance in making a claim, – or would like to look at challenging a denied claim, please do not hesitate to call us. We’re here to help.