What criteria must I meet to lodge a successful TPD claim?

Many people are unprepared should the unthinkable happen. If you fall permanently disabled due to personal injury or illness, are you equipped to cover the costs? Total and permanent disability (TPD) can help you along the way and has an 89.5% acceptance rate through group life insurance according to ANZIIF. 

We will explore how to lodge the claim and what to do when you face challenges along the way toward earning TPD compensation.

What is TPD insurance and what does it cover

If you’ve been injured by an accident or incurred an illness and you are unable to now perform your duties on the job, you could be eligible to lodge a TPD claim. Insurance can cover a series of necessary expenses such as:

• Care support.
• Debts like your mortgages. 
• Disposable income in case your partner needs to leave work to care for you. 
• Medical treatment, rehabilitation, pharmaceuticals and other expenses not covered by your health fund or Medicare. 

TPD insurance does not take the place of your regular life insurance and could in fact reduce the amount it covers based on how much you receive from TPD. However, what your TPD covers will depend on the insurer. 

If you’re deciding if you need TPD cover, consider whether you and your family have the means or other types of insurance to cover your needs should you not be able to work. There are two definitions of TPD insurance you can choose from to help cover expenses: “any occupation” and “own occupation.” Any occupation means you are unable to return to work in any capacity, no matter your skills or qualifications. Own occupation refers to an event where you are unable to return to the job you previously were in prior to the injury or illness. 

Depending on how your insurer defines TPD coverage, it may be helpful to hold insurance through your superannuation as well. 

Insurance through a superannuation policy

Superannuation policy funds can offer several types of insurance such as life cover, TPD and income protection. As you increase your super fund, it will automatically provide you with life cover and TPD. Some will include income protection as well, through a specified amount available without checking medical wellness. 

TPD insurance cover will end around the age of 65 and life cover will end around the age of 70. However, insurance will not be provided for people under the age of 25 or if an account balance is under $6,000 unless you contact your super and request insurance, or your work in a dangerous field. 

There are many pros and cons associated with getting your insurance through your super:

Pros:

• Premiums are often cheaper. 
• Easy, tax-effective payments. 
• Increased cover.
• Few health checks.

Cons:

• Cover reduces your super balance.
• Limited cover compared to an outside super fund. 
• Cover could end if you change accounts.

TPD insurance vs. income protection

If you have income protection, do you need TPD insurance as well? First, it’s worth defining the terms. The difference between the two lies in how the compensation is paid. Income protection will give you a payout on a monthly basis whereas TPD is typically a lump sum payment. 

While you can claim temporary TPD, income protection insurance is better suited to cover you while you are out of the job but will be returning. Income protection could last up to five years but the longer the benefit, the more expensive the policy. Additionally, income protection only covers 75% of your regular wages. While this could help supplement your income, it won’t necessarily help with the additional medical expenses you may have following an injury or illness. 

TPD insurance benefit is best to supplement income protection in the event that your injury or illness proves to be permanent. 

How to file a TPD claim

If you’ve found yourself away from work for three to four months and have no prospect of returning then you could be eligible to make a TPD insurance claim. You may have to check your TPD policy on claim eligibility but typically if you’ve been out of work for at least six months and doctors are not confident you’ll ever be able to return, then you should be eligible. 

There are some basic conditions to filing a claim as well such as:

• You can prove your work history.
• You are complying with ongoing medical care. 
• You have lost some or all of your independence.
• Your disability is total and permanent. 

To be eligible to make a TPD claim, you must contact your super and complete the forms they offer you. You’ll need to go through an assessment, then your super fund will pass your TPD claim over to an insurer to perform another assessment. From there, the insurance company will determine whether to approve or deny your claim. 

To successfully complete the form you will need:

• A valid and active coverage policy.
• A completed application form. 
• Medical records documenting your injury or illness.
• Workers compensation files if applicable. 
• A thorough written submission explaining why your TPD claim should be approved. 

Many insurance offices receive hundreds of submissions every year. After you turn in a completed application, you will want to follow up with the insurer to make sure they don’t need anything beyond what you provided. The process could take up to six months before you receive an answer. 

Once the income protection claim has been accepted, it will take more than 2-3 months to receive compensation. However, if your claim is taking too long, you may want to file a complaint to the insurer, the superannuation fund or the Australian Financial Complaints Authority (AFCA). 

Hiring superannuation lawyers for legal advice could be your best bet for streamlining your TPD benefit claim and minimising the possibility of a denied claim. 

Why should you work with a lawyer?

You may have been injured or fallen ill but be unsure whether you should apply for TPD. Some people who are rendered unable to work in their respective fields may not realise that they qualify. Here are some injuries, illnesses and mental health conditions that would qualify:

• Anxiety. 
• Schizophrenia.
• PTSD.
• Cancer.
• Multiple Sclerosis.
• Alzheimer’s Disease.
• Loss of a limb.
• Carpal Tunnel.
• Spinal fusions.

This is not an exhaustive list, and it helps to speak with your doctor about your injury. Once you begin receiving treatment or a diagnosis, schedule an appointment with a lawyer who can guide you to take the first steps towards compensation. Your doctor does not work in the field of law and can only offer solutions for your physical or psychological condition. Your lawyer, however, can help you earn the compensation you need to cover your medical bills and the expenses necessary to carry on your life. 

It’s not uncommon for a TPD claim to be denied initially because the injured party submitted their own application. One mistake can greatly push back your road to approval. Working with a lawyer can help you decide on how much of your super fund you can use for your TPD and navigate the nuances of a claim.

When you hire a TPD lawyer, you can take the stress of dealing with court and forms off your plate and instead focus on your recovery, or maintaining some percentage of normal life after your injury. Your lawyer can work with you to identify what your insurance actually covers and uncover any obscure TPD definitions it may entail. 

The claims process could move along more quickly with legal assistance and your lawyers will likely write the letter of intent around your need for TPD.

If your compensation claim is denied initially, this is not the end of the road. Your lawyer can dispute the insurer’s decision and help you get the compensation you need. 

Gerard Malouf & Partners is the leading Australian no win no fee law firm specialising in maximising compensation for TPD claims. Give us a call today for a no-obligation consultation and start your road to recovery.