When you’re injured or sick and you’re unable to work, you may be eligible for a TPD claim if you have TPD insurance. It’s important to determine what insurance, if any, that you have as many people have insurance that they don’t even know about. As TPD Lawyers, we frequently see people who have large TPD insurance policies which they had no idea 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

    The definition as to what it means to be Totally and Permanently Disabled can differ significantly across trust deeds and policies of insurance.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 which 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 insurer’s are permitted to take into account when determining claims regarding the various types of policies.It is critical to know what kind of policy you have, and also understand the different components of a definition that can vary. If you believe you satisfy the definition under the respective policy, then you can begin to obtain the evidence that proves you satisfy the definition.

  2. The Claim Form

    Obviously, most claims processes start with an initial claim form. As TPD lawyers, we come across most of the claim forms. They all require different information – though have many similarities. It is important to have an understanding as to 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. Generally a TPD lawyer will be familiar with the claim form, and will understand why the insurer requires the information they are requesting. 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 insurer’s request that claimant’s 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. By way of example, 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 ensure the information provided in the claim form is accurate and gives your claim the best chance of succeeding.

  3. Medical Evidence

    Obtaining appropriate medical evidence in support of your claim is a key part of ensuring a claim’s success. As TPD Lawyers, we have found that it is critical to ensure Doctors are appropriately instructed 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.Furthermore, it is often the case that more medical records will be required and obtaining reports from multiple treating practitioners is needed. With TPD claims, it can be the case that other illnesses/injuries/disabilities that you have had prior to your main illness is relevant to your claim. For instance, if you had a bad ankle – but was able to work, and then hurt your neck badly and were unable to go to work, it would be helpful to ensure that the insurer understands the restrictions which your ankle placed upon you as the ankle injury may be relevant to why you cannot work in other suggested professions where your neck injury alone would not prevent you working. That is to say, 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. 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 your claim meets 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 and reasons why you may be unsuited to specific roles which you may appear, at face value, to be fit for. As mentioned, your TPD lawyer may want to put on treating doctors evidence, documents from your employer and perhaps even Medicolegal evidence.

  5. Chasing the Insurer

    Once the ball is in the insurer’s court it is important to chase them to ensure a decision is made. In our experience as TPD Lawyers, we’ve found that even when we feel the insurer has everything they need to determine the claim, they will often sit on the claim without response for long periods of time. It is extremely frustrating when the insurer waits a long period of time but this is particularly so when they subsequently require a further piece of evidence. It’s important to ensure the insurer act within reasonable time frames and where possible, remind them to keep to those time frames. Otherwise, claims can be unnecessarily drawn out and lose momentum accordingly. This means your claim can meet other obstacles such as landing in the hands of new claims officers who aren’t familiar with the claim. This can cause further delays.

  6. Sometimes, don’t take ‘no’ for an answer

    Just because the insurer denies the claim the first time, 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 as to why they have denied the claim. 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 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 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 any application for review.

    As TPD Lawyers, we feel that it’s often the case that applications for review are a great way to have the insurer determine a claim and provide a positive result. It is a process that allows a claimant to alleviate issues that the insurer may have about the claim.

  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 should then assess the prospects of success in your case and advise you as to whether you should challenge the insurer’s decision. Most of these matters are run in the Supreme Court and it is important to consider what evidence has been provided, as well as legal precedent to determine 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 that if you lose, you may have to pay the other side’s legal costs. 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.

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