Tips and Traps for TPD Claim Approval

Hi everyone

Welcome to the July 2025  ‘Latest Happenings’ in Personal Insurance Claims.

This month I be discussing some ‘tips and traps’ surrounding getting complex TPD claims over the line.

There are several ways insurers delay, decline and drag their feet on TPD claims.

One of the main tactics I find very frustrating is not asking for the information they want all at once. While they expect you to provide everything to them at one time to get the claim started (and if you don’t, this will just provide them with even more ways to drag things out), On the other hand, the insurers ask for information piecemeal so that it turns into a long drawn out game of chess, eg. They ask for something, you give it to them, so they ask for something else, etc…. and this goes back and forth for weeks, months, and in some cases, years.

A few other favoured ways to avoid paying claims are… the ‘medical treatment clause’

This is why it is ESSENTIAL to understand what the PDS relating to your insurance product actually says.

I find the ‘all reasonable treatment’ clauses a very grey area that insurers misuse in many ways. For example, they often say someone “hasn’t explored all treatment options” (as if people could afford to fly off around the world trying new things without their insurance funds) or “their condition hasn’t stabilised enough for them to be deemed total and permanently disabled”…or “there is a surgical option they could try” even though that surgery carries significant risks, all this is used to basically say ‘go away and come back in a year or so’ hoping that people just give up in despair. This is where a good insurance claim’s advocate comes in. We are able to get all the correctly worded medical reports from the beginning of the claim process, before you provide reports that may have ambiguous meanings and allow things to slide into the grey areas that insurers use to avoid and delay TPD claims. Often people with mental health issues see a psychologist, which their GP considers perfectly adequate for their health condition. However, the insurers need reports from two medical doctors (and a psychologist is not a medical doctor) so an evaluation by a psychiatrist will be needed (not only can these doctors take a long time to get an appointment with, but they can also be quite costly).

While on the subject of doctors, I believe it is always best to pay to get your own independent medical reports, rather than using the insurers preferred medical experts. In my experience, if the doctor is paid by the insurer, this is a conflict of interest and they tend to support the insurer’s views.

Many TPD insurances held in super funds for an ‘any occupation’ definition, say things like the below (taken from Australian Super):

The main part of the above definition that insurers use to delay and deny TPD claims are “you’re incapable of ever working in any job that you’re reasonably suited to based on your previous education, training or experience, or any job that you may reasonably become suited to with further education, training or experience within a reasonable period”.

The Insurer will consider things such as:

• what re-skilling, retraining or voluntary work you’ve done already
• any retraining or re-skilling you reasonably could be expected to do, and
• any rehabilitation you’ve done already or any rehabilitation you reasonably could be expected to do.

This is why insurers ask for resumes, which list all your work and education/training. They will be looking for something they think you can do in the future, even if you can’t do your most recent job (or longest occupation). This is a great argument for why ‘own occupation’ TPD definitions are so important for people with specialised skills and knowledge. See my June article which discusses the differences between group and retail insurance policies for more information on this.

Your two TPD medical reports need to clearly state that you will never (or unlikely to) be able to return to any job that you’re reasonably suited to based on your education, training or experience. If your doctor starts saying things like ‘X might have some capacity to return to their role part-time in the future’ or anything along this line, the insurer will grasp onto that as an excuse to delay or deny your claim. Your doctor might not realise that, and think they are helping give you some hope for the future, but you need to shut that down, which is why getting an insurance claims’ advocate to check all medical reports BEFORE they go to the insurer is so valuable.

I hope that has helped you see how important it is to know what the PDS definition is for your TPD policy, and make sure your DV, claim forms and doctor’s reports help you meet that definition.

Come back next month for another discussion on the ‘latest happenings’ in the world of personal insurance claims. I will be writing about some of my most interesting/challenging claims’ cases, and how the insurers can throw various crazy spanners in the works to dispute and decline claims.