Receiving a denial of a Total and Permanent Disability (TPD) claim can be frustrating and overwhelming, particularly when you are already dealing with the physical, psychological and financial consequences of an injury or illness. Many people assume a rejected claim is the end of the process. In reality, a denial does not necessarily mean you are not entitled to receive TPD benefits.

Understanding why your claim was denied and what options remain available is an important first step towards protecting your rights.

What Is a TPD Claim?

A TPD insurance claim is generally made through a superannuation fund and may provide a lump sum payment if an injury or illness prevents you from returning to work.

The amount payable and the requirements for a successful claim will depend upon the terms of the specific insurance policy. Different policies may have different definitions of “total and permanent disability” and different eligibility criteria.

Why Are TPD Claims Denied?

There are a number of reasons why a TPD claim may be declined, including:

• The insurer believes you do not satisfy the policy’s definition of TPD.
• Insufficient medical evidence has been provided.
• The insurer considers that you have the capacity to return to work in some form.
• The insurer disputes the severity or permanence of your condition.
• Information provided in the claim is incomplete or inconsistent.
• The insurer relies upon surveillance, medical assessments or vocational evidence that it says is inconsistent with the claim.

Importantly, a claim being denied does not necessarily mean the insurer’s decision is correct.

The First Step: Understand the Reasons for the Denial

If your claim has been rejected, you should carefully review the insurer’s decision letter.

The letter will usually set out:

• The reasons for the decision.
• The evidence relied upon by the insurer.
• Whether any review or appeal rights are available.

Understanding exactly why the claim was rejected will often help determine the most appropriate next steps.

Can a Denied TPD Claim Be Challenged?

In many cases, yes.

A denial may be challenged where there is evidence that:

• The insurer has incorrectly interpreted the policy.
• Relevant medical evidence has not been properly considered.
• Additional medical or vocational evidence supports the claim.
• The decision was unreasonable or unsupported by the available evidence.

Many successful TPD claims have initially been declined before being approved following further review or legal intervention.

Additional Medical Evidence May Be Required

One of the most common reasons for a denied TPD claim is a lack of sufficient supporting evidence.

Obtaining further reports from:

• Treating specialists;
• General practitioners;
• Psychologists or psychiatrists;
• Occupational therapists; or
• Other relevant medical professionals

may assist in demonstrating how an injury or illness affects your ability to work and why your condition is unlikely to improve sufficiently for a return to employment.

Internal Reviews and Complaints

Depending on the circumstances, a review of the decision may be available through the insurer or superannuation fund.

This may involve providing further evidence and requesting that the decision be reconsidered. In some cases, disputes may also be referred to external dispute resolution processes.

Strict time limits can apply, so it is important not to delay if you wish to challenge a decision.

When Should You Obtain Legal Advice?

TPD claims can be complex, particularly where insurers rely upon competing medical opinions or argue that a person retains some work capacity.

Obtaining legal advice may assist with:

• Reviewing the insurer’s reasons for denial.
• Interpreting policy definitions.
• Gathering additional evidence.
• Preparing review submissions.
• Challenging decisions through appropriate dispute resolution processes.

Early advice can often help identify issues that may improve the prospects of a successful outcome.

Don’t Assume a Denial Is the Final Outcome

A rejected TPD claim can be discouraging, but it does not always mean your entitlement ends there. Many decisions can be reviewed, challenged or overturned where appropriate evidence supports the claim.

If your TPD claim has been denied, understanding the reasons for the decision and obtaining advice about your options may significantly improve your chances of achieving a successful result.

How Don Cameron & Associates Can Help

At Don Cameron & Associates, we assist clients throughout regional New South Wales and Victoria with a range of compensation matters, including TPD claims.

If your TPD claim has been denied and you are unsure what options are available, our team can review the decision, explain your rights and provide practical advice about the next steps.

A claim denial is not always the end of the road. Seeking advice early can make a significant difference to the outcome of your matter.