What to do if your TPD claim is denied
If you’re injured and permanently unable to work, a TPD (Total and Permanent Disability) claim can offer essential financial support.
However, getting your full benefit isn’t always as simple as having a TPD policy and submitting a claim. Your claim could be denied for several reasons, including not meeting your policy’s requirements or failing to provide enough evidence.
The silver lining? A denied claim doesn’t mean you’re out of options — you have the right to appeal. Keep reading to learn how to challenge a denied TPD claim and what to expect during the appeals process.
Why was my TPD claim denied?
Your claim could be denied for various reasons, such as:
- Not meeting your policy’s terms, like its definition of TPD, minimum waiting periods, or work history requirements.
- Medical evidence from your super fund or insurer contradicting your own.
- Providing insufficient supporting documentation.
- The super fund or insurer suspecting your claim is fraudulent.
- Still being able to do some work (depending on your policy type).
This isn’t an exhaustive list; super funds and insurers can deny claims for many reasons.
If your claim has been denied, get in touch today — especially if you made your original TPD claim on your own. Our specialist lawyers can determine whether you have an appeal and the best strategy for securing your full TPD benefit. This service is completely free, and there’s absolutely no pressure to keep working with us afterwards. But if you do decide to proceed, our No Win No Fee guarantee covers all upfront costs, so there’s nothing to pay until we win your case.
What should I do if my TPD claim is denied?
Before your TPD claim is officially denied, the insurer will send a ‘procedural fairness’ letter, explaining why they’re planning to deny it, along with the evidence and policy definitions they’re using to back up their position. You’ll usually have 28 days to respond with any extra evidence or arguments. Once they review your response, the insurer will make a final decision and pass it to the trustee to assess.
If your claim is denied, your super fund or insurer should send you an official letter explaining why. If you haven’t received this, be sure to ask for a copy. This letter will also outline the specific appeals process for your fund or insurer. While each process differs slightly, your appeal will usually follow these steps:
- Request an internal review.
- Submit a complaint to the Australian Financial Complaints Authority (AFCA).
- Challenge the decision in court.
We’ll go over each option in more detail below.
Importantly, you’ll need to meet all your fund or insurer’s requirements to make a successful appeal. Before going ahead, it’s important to chat with an experienced lawyer. We’ll look over your rejection letter and give you valuable insights on why your claim was denied and the best approach for a successful appeal.
Insurers have notoriously large legal teams, so having a lawyer in your corner levels the playing field. And the best part? We’ll assess your denied claim for free, so there’s nothing to lose by reaching out.
1. Request an internal review
If you disagree with the decision, your first step is to request an ‘internal review’ by your super fund or insurer. This means you’re asking the super fund or insurer to reassess their decision about your claim.
As part of the internal review, you’ll need to provide documents that show:
- Why you’re requesting an internal review.
- What outcome you’re hoping for.
- Medical documentation from independent medical professionals that support your claim.
- Details of the decision you believe should be reconsidered, and your reasons for this.
In most cases, you’ll need to request a review within a month of receiving your decision, though it varies by state. For example, in NSW, you must apply for an internal review within 28 days.
It’s crucial to speak with a lawyer before this deadline, as the internal review is your best chance to get a denied claim approved. If the insurer stands by their decision, it can get significantly harder (and more expensive) to challenge it later on.
The good news? Our expert lawyers are well-versed in the internal review process and know exactly what it takes to get a denied claim approved. We’ll take care of everything: from completing all forms and meeting deadlines to gathering strong new evidence proving your case. This thorough approach gives your internal review the best possible shot at success.
Once you request a review, the super fund has 45 days to either uphold or overturn the decision. If you’re appealing through an insurer, they must do this within 30 days.
If the fund or insurer upholds their decision, the next step is to file a formal complaint with the Australian Financial Complaints Authority.
2. Submit a complaint to the Australian Financial Complaints Authority
If the internal review doesn’t change the outcome of your TPD claim, your next move is to file a formal complaint with the Australian Financial Complaints Authority (AFCA). You’ll usually need to do this within two years of getting the results of your fund or insurer’s review.
The AFCA offers both informal and formal ways to resolve disputes. Let’s walk through what happens with your claim when it goes through the AFCA.
- Get a case manager: once you file your complaint, you’ll be assigned a case manager who will gather all the relevant documents and evidence from both you and the fund or insurer.
- Negotiations begin: the AFCA often begins the appeals process off by helping both parties negotiate a resolution. This means you and the fund or insurer will go back and forth, exchanging offers and discussing the reasons behind each one. Since negotiations can be complex — and the fund or insurer will likely have a legal representative — it’s a good idea to have a qualified lawyer by your side during this process. The AFCA will guide these negotiations and explain what could happen if you can’t reach an agreement. They’ll also outline potential outcomes for more formal methods of dispute resolution, like a determination.
- Attend conciliation: this works similarly to negotiation but allows both parties to present their arguments and listen to each other, with an AFCA representative facilitating the conversation. During this process, the AFCA rep will provide guidance on the issues raised and suggest the best ways to resolve the dispute.
- Receive the case manager’s recommendation: if you can’t settle things during the conciliation, your case manager will issue a recommendation. This is their way of explaining the outcome they believe is fairest based on the facts of the case and the law.
- Agree or disagree with the recommendation: the case manager’s recommendation is only binding if both parties agree to it. If either side doesn’t accept it, the complaint will move on to the Financial Services Ombudsman.
- Receive the Ombudsman’s determination: if you accept the Ombudsman’s determination, your super fund or insurer must comply. However, if you don’t agree with the determination, you still have the option to take your case to court.
Over the years, we’ve navigated many cases through AFCA and are ready to do the same for you.
If the insurer still refuses to pay your full benefit, our experienced lawyers are ready to take your claim to court. Throughout this process, you’re still protected by our No Win No Fee guarantee — so you can relax, knowing there’s nothing to pay unless we successfully resolve your claim.
3. Challenge the decision in court
While the specific process may vary based on your situation, here are the typical steps involved in making a court claim:
- Lodging a statement of claim: this document is submitted to the court to formally initiate your claim.
- Insurer or fund’s response: the insurer or fund must then file a response to your statement of claim.
- Discovery process: both parties will exchange all relevant documents related to the claim during this stage.
- Pre-court mediation: the matter is usually referred to a mandatory mediation before going to court. If mediation fails, the case will proceed to court.
- Interrogation: an interrogation may take place, where the other party will question you about the circumstances, outcomes, and issues related to your claim. The statements from this process will be shared between both parties.
- Court hearing: finally, both parties will present their case in front of a judge.
Unfortunately, the court process is complicated and may take months or even years to resolve. While it can be a tough journey, a successful claim could lead to significant benefits, such as receiving your TPD benefit, additional compensation for the fund or insurer’s conduct, and coverage for your legal costs.
Having a skilled TPD lawyer on your side is essential during the court process. They’ll help you gather and present all the necessary evidence, prepare you for interrogation, and build a strong case that’s tailored to your unique situation. Their expertise ensures a smooth appeals process and gives you the best chance of securing your full TPD benefit.
How we can help you
If your TPD claim has been denied, we’ll help you navigate the complex appeals process and secure your rightful benefit. Our team will assist at every stage of your claim, including:
- Expert case evaluation: your lawyer will carefully review your denial letter and TPD policy to pinpoint the best grounds for your appeal.
- Explaining your rights: your lawyer will ensure you understand your rights throughout the appeal process.
- Collecting evidence: we’ll help you gather the necessary medical evidence to build a strong foundation for your appeal.
- Drafting your appeal: your lawyer will craft a persuasive appeal letter that clearly explains why you’re contesting the denial and emphasises the supporting evidence.
- Time limits: we’ll keep track of critical time limits, ensuring all documents are submitted on time to avoid any delays in the process.
- Negotiations: your lawyer will handle all negotiations with the fund or insurer, using their expertise to advocate for a favourable outcome.
- Mediation and court: should your appeal go to mediation or court, your lawyer will prepare you for the proceedings. We’ll represent you during the mediation process and, if necessary, we’ll brief a barrister to present your case in court.
Whether your claim has just been denied or you’ve started the appeals process on your own, we can help. Our expert lawyers are always ready to provide free, tailored advice on your denied TPD claim.
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