If you’re injured and permanently unable to work, a TPD claim can provide much-needed financial relief. Unfortunately, receiving your full benefit is not always as simple as having a TPD policy and filing a claim.
A super fund or insurer may reject your claim for a number of reasons, including:
- Not meeting the terms of your policy, such as its definition of TPD, minimum waiting periods and work history requirements.
- The super fund or insurer’s medical evidence contradicting your own.
- Providing insufficient evidence.
- The super fund or insurer believing your claim is fraudulent.
- Still being able to do some work (depending on the type of policy you have).
This is by no means a complete list — super funds and insurers can reject your claim for many reasons. But that doesn’t mean a rejected claim is the end of the line: you can appeal the decision to the fund or insurer, the Australian Financial Complaints Authority, or even take your case to court.
Appealing a rejected claim
Get a copy of the rejection letter
In most cases, your super fund or insurer will send you a letter outlining why your claim has been rejected. If you haven’t received this, it’s important to ask for a copy.
The letter will outline your fund or insurer’s specific appeals process. You must meet all their requirements to make a successful appeal.
Before starting, we suggest seeking legal advice from a specialist TPD lawyer. They will assess both the letter and your TPD policy, and ensure you have a valid basis for an appeal.
Lodge your appeal
You can lodge an appeal with the original decision maker, whether that’s your super fund or insurer. As part of this, you will need to submit documents that clearly outline the reasons for your appeal. You may also need to gather new evidence supporting your case.
Once you’ve lodged the appeal, the super fund has 45 days to review the decision and either uphold or overturn it. If you’re appealing to an insurer, they will need to do this within 30 days.
Lodge a complaint with the AFCA
If you’re unhappy with the result of the fund or insurer’s internal review, you can lodge a complaint with the Australian Financial Complaints Authority (AFCA). They will assess whether your super fund or insurer followed the correct steps when assessing your claim. If they didn’t, the AFCA may recommend that your rejected claim be overturned.
The process can differ slightly depending your fund or insurer, but your case will generally follow this process:
- You lodge a complaint: Generally, you must lodge your complaint within 28 days of your TPD claim being rejected.
- You are assigned an AFCA case manager: They will get all relevant documents and evidence from both yourself and the fund or insurer.
- They mediate the complaint: You will attend a conciliation conference, where the case manager mediates a discussion between yourself and the fund or insurer.
- A recommendation is delivered: If you cannot resolve the complaint through the conciliation conference, the case manager will issue a recommendation. This means they explain the outcome they believe is fairest, considering the facts of the case and the existing law.
- Both parties must agree: The case manager’s recommendation is only binding if both parties accept it. Otherwise, the complaint heads to the Financial Services Ombudsman.
- The Ombudsman delivers a final determination: If you accept the Ombudsman’s determination, your super fund or insurer must comply with it. But if you don’t accept the determination, you can take your case to court.
Go to court
At this stage, we highly recommend speaking to a lawyer — even if you started your appeal alone. The court process is complex and potentially costly, so it’s important to get strong legal advice before starting.
Court processes differ from state-to-state, but your case will likely follow these steps:
- You begin court proceedings: This usually involves filing a statement of claim or similar document with the court. You must do this within 6 years of your TPD claim being rejected.
- The super fund or insurer responds: Their response is a defence to your statement of claim, and will outline the reasons for rejecting your TPD claim.
- You exchange documents and evidence: Both parties’ legal teams will exchange any documents and evidence relevant to the claim.
- You attend mediation: You must attend a pre-court mediation where a court-appointed third party will try to resolve the dispute.
- Go to court: If mediation fails, you’ll proceed to court. At the end, the judge will hand down their decision, which is binding.
How we can help you
If your TPD claim is rejected, your lawyer will immediately start work on your appeal. We’re experts in challenging super fund and insurance company decisions, and know the best tactics to get unfair results overturned. On top of this, we offer a genuine No Win No Fee guarantee. This means we cover all upfront costs, and there’s nothing to pay until we win your claim.
If you made your TPD claim alone or with another firm, we can provide a free second opinion and help you dispute the decision.
It’s important to know that strict time limits may apply to disputing a TPD decision. To find out more about having your rejected claim overturned, talk to our lawyers today. It’s never too late to find out where you stand.
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