Client Stories

Hi everyone

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

This month I be discussing three of my most interest claim’s cases:

1. Last year, a new client came to me, unhappy that his insurer had advised that his own occupation TPD claim as dentist was likely to be declined. The reason given for this, was that his ‘hobby business’ of wine making was now considered to be his own occupation. A finding my client was quite surprised, and not at all pleased, to hear! Especially since he didn’t pay himself any wages, and just put the money generated back into the business for future losses and to keep the business solvent. I responded to the Procedural Fairness letter (a stage before a decline is issued, at which point you can submit any new evidence). However, the insurer proceeded to decline the claim. In response, we lodged a complaint to the insurer’s internal dispute resolution team. Fortunately, this came back with the desired result, after several months of arguing and presenting the evidence based on education, training and experience, the client in question was indeed to be assessed as a dentist! The insurer then reverted to trying to avoid paying the claim based on medical evidence and “having tried all reasonable treatments”. We also had to get a psychiatrist’s report as the client’s psychologist is not considered as a medical document by insurance companies. Getting an appointment with psychiatrist often entails quite a long wait, but fortunately the client didn’t have to wait more than a month. Once the insurer received that report, the claim was finally approved a short time later, much to everyone’s delight (well, our delight, not the insurer’s!) It was a real battle and the client himself said he never would have got it approved without a specialist fighting on his side. It’s a real example of how much stress trying to deal with insurers put on people who may already be suffering from mental health problems. Most insurers count on the person just giving up on their claim, because it becomes too difficult and confusing, which I find very sad.

2. My next case study, centres around a medical centre cleaner who was shocked (excuse the pun) to be struck by lightening on a 2 minute walk across a car park on a sunny, partially cloudy summer’s day. The lightening hit the ground and conducted up the metal mop he was holding, throwing him across the car park. He immediately began to experience a variety of symptoms, such as spatial awareness issues, which lead to car accidents, blurred vision, bloody noses, left side body weakness etc. The condition continued to deteriorate with more issues, such as tremours, seizures and nerve pain among others. The client was eventually diagnosed with Functional Neurological Disorder (FND) and was also declared legally blind by a neurologist, leading to the loss of his driver’s licence. The insurer seemed to think he was ‘totally blind’ (their mistake) and the ophthalmologist they sent him to failed to read the medical reports provided to him, and wrote a report for the insurer accusing the client of ‘malingering’ (lying) and making everything up. Fortunately, my searing five page response eventually led them to not only accept the claim, but also pay a year of interest for dragging the assessment process out for so long.

3. My final case study revolves around a lovely lady who came to me because she was scrubbing around for funds to pay her bills and had had her income protection claim rejected. She had previously, been on income protection for the same issue a couple of years before, so when I realised the insurer had closed it, rather prematurely in my view, I decided to dig a little deeper. Sadly, for the insurer (sarcasm) and very happily for the client, the insurer ended up owing her back payments and refunded premiums to the tune of around $500,000! The client no longer has trouble paying her bills and has been enjoying travelling the world and renovating her home. I do love a happy ending

Join me for more exciting happenings in the world of personal insurance next month.