How to Prepare a Strong TPD Claim

How to Prepare a Strong TPD Claim

This guide explains what a strong TPD claim typically looks like, what evidence you will need to gather, and the steps you can take to give yourself the best chance of success.

Does Your Policy Require an Any-Occupation or Own-Occupation Definition?

One of the most important parts of preparing a TPD claim is identifying which definition of disability applies to you. Differing policy definitions can make the difference between being found totally and permanently disabled or being told you still have some capacity.

Most superannuation policies operate under the any-occupation definition. This means you must show that you are unlikely ever to be able to work again in any job that matches your education, experience and training. It is essential to understand that insurers are not assessing whether you could return to your pre-injury occupation, but rather, any work. For example, if you were previously a construction worker but injured your back, insurers may argue that you could return to work in an office role within the construction industry. However, the job that insurers argue you can return to must be realistic, align with your actual background, and be consistent with your medical limitations.

Some policies use the own-occupation definition. This means you will only need to prove that you are unable to return to your specific occupation.  Even if you could realistically do something else. Own-occupation policies are more common in private retail insurance and income protection policies.

It is vital to understand and read the policy wording carefully. A claim built for an any-occupation definition requires evidence regarding your experience, transferable skills, and vocational capabilities. However, a claim for an own-occupation definition focuses on the impact of your disability on your current duties. To know which evidence to prepare for your claim to be successful, you must know which test the insurer will apply.

Medical Evidence: What Doctors Need to Say for Claims

Strong medical evidence is essential in building a strong TPD claim. Insurers will look for detailed, long-term information about your diagnosis, your current capacity to work, and the likelihood of recovery.

They must describe your diagnosis beyond just a label. A diagnosis such as “chronic pain” or “anxiety” needs to be strongly supported by clinical observations, symptoms, and investigations. Insurers are likely to reject claims if the diagnosis is unclear or lacks medical evidence.

You will likely need reports to outline your functional impairment. This means describing the tasks you are unable to do, how long you can sit, stand, or concentrate, and, overall, how your disability impacts your daily life.

Another crucial area is your treatment history. The insurer will look closely at what treatment you have had, how you responded, and whether any further treatment is recommended. Doctors should explain whether your condition is stable or deteriorating and whether further improvement is realistically expected. If your prognosis is uncertain or there are suggestions that you could return to work, the insurer may delay or decline the claim.

Finally, the medical evidence must express a clear opinion about permanency. While doctors are not asked to guarantee the future, they must be prepared to say that, in their professional view, you are unlikely ever to return to work again in the type of roles defined by your policy. Some doctors hesitate to use the word “permanent,” not realising how essential it is. A reluctance to commit can cause significant delays or outright rejection.

The stronger your medical evidence is, the harder it is for the insurer to reject your claim.

Vocational Evidence: Proving Loss of Work Capacity

You will need strong vocational evidence to support your claim. Insurers will assess your work capacity, skills, education, and employment history. A vocational assessment examines whether you have the capacity, background, or training to perform work aside from your previous role. It takes into account your age, transferable skills, skill set, and the restrictions caused by your impairment.

Strong vocational evidence challenges the assumptions that insurers usually use to rebut TPD claims – that claimants can perform lighter or alternative roles. Strong evidence will challenge these assumptions by detailing how it would be unrealistic for you to return to work in any role. For example, a construction worker with significant mobility issues may still struggle with the physical demands of a supervisory role.

Practical Checklist and Template Documents to Give Your GP and Specialists

Giving your GP and specialists a guideline on what to include in documents can help make the claim process smoother.

A strong set of documents for your doctor includes:

• a background summary;
• a list of functional questions;
• your job description or list of duties;
• the insurer’s medical certificate or statement form;
• any recent investigations or hospital discharge summaries.

Preparing a short summary outlining your work history, symptoms, daily limitations, and the type of policy definition that applies to you will help your doctors understand your case and what evidence is needed. If your disability is physical, explain to your doctors how it affects your ability to work, including your lifting capacity, mobility, and pain levels. For psychological claims, it may include memory, concentration, or the ability to manage stress.

You should also ask your doctors whether your condition has stabilised, what treatment you have undertaken, whether further treatment is possible, and how likely it is that you could return to work in the future. These are issues insurers always focus on. Addressing them upfront avoids delays caused by the insurer seeking clarification later.

The medical evidence given in your reports must be clear and consistent, so it is crucial to be upfront with your doctors.

Common Pitfalls and How Garling & Co Can Help

Many TPD claims fail because the initial stages of the claim were rushed. It is important to ensure that every part of the claim is correctly prepared before lodging. From gathering the necessary medical and vocational evidence to completing the claim form, everything must be done accurately. This is where Garling & Co can help!

At Garling & Co, we have a thorough understanding of what information insurers are looking for, how to interpret policy definitions, and what insurers are likely to rely on if they were to reject a claim. When starting your claim we will guide you throughout the process and put you in the best position for a successful outcome.

If you need assistance or have questions about your claim, don’t hesitate to reach out to Garling & Co. Call us on (02) 8329 9500 or visit our website at www.garlingandco.com.au for more information. For further guidance, check out these helpful resources: Superannuation & Insurance Claims, Total Permanent Disability (TPD) Claims, and article “What do I do if my TPD claim is denied?’