What To Do If Your TPD Claim Has Been Denied

Step-by-step guide to challenging a denied Total and Permanent Disability (TPD) claim

Denied a Total and Permanent Disability (TPD) claim? Discover the essential steps to take if your TPD claim has been declined and how you can improve your chances of success. Being denied a TPD claim can be both frustrating and disheartening.  Particularly as you often make this claim due to being injured and unable to work. It is important to understand that rejection is not the end of the process. A denial can often be due to insufficient information provided to the insurer.  Or that they misunderstood the evidence you have provided. With the right strategy, you can challenge the decision and improve your chances of approval.

At Garling & Co Lawyers, we regularly help clients whose initial TPD claims were rejected—many of whom later had their claims approved after a proper review.

Below, we outline the common reasons TPD claims are declined, the steps to take after a denial, and how a TPD lawyer can maximise your chances of a successful appeal.

Common Reasons Why Insurers Decline TPD Claims

You Do Not Meet the Definition of TPD

Each superannuation policy has its own definition of TPD that you must satisfy. Standard criteria include being unable to return to your usual or any occupation reasonably suited to you, and your impairment being permanent.

Insurers might argue you do not meet the definition if they believe you could, in some capacity, perform a form of work. For instance, a construction worker unable to do heavy lifting might be rejected if the insurer claims the worker could undertake a supervisory office role.

Insufficient or Inconsistent Medical Evidence

Strong medical evidence is crucial for your TPD case, which is why legal assistance is recommended. Your medical evidence must be substantial, consistent, and address your functional capacity. For example, reports stating you have ongoing back pain but failing to explain how it restricts your work may be deemed insufficient. Consistency between reports from your GP and specialists is also essential; if your GP finds you unfit for work but a specialist suggests you could do light duties, insurers are likely to rely on the specialist’s opinion.

Vocational Evidence Missing

Vocational reports are different to medical reports and need to be supplied as part of your evidence. They are vital because they assess your work capacity. Claims can be denied due to missing or insufficient vocational evidence. Without this evidence, insurers may assume you can work part-time, have changed roles into something that accommodates your injury or have modified your existing role and are performing light duties for you.

Administrative Errors

Even small mistakes can impact your claim. Incorrect forms, delayed lodgement, or missing factual details can result in a denial. This does not mean your condition is not genuine—just that the insurer does not have enough information to approve your claim.

Contradictory Information

Any inconsistencies in your evidence can be used against you. For instance, if you claim difficulty lifting heavy items but are seen on social media carrying grocery bags, the insurer may interpret this as evidence that you can do moderate lifting. Ensure your evidence is consistent to avoid such issues.

Step-by-Step: What to Do After a TPD Claim Denial

Step 1 – Request an Internal Review

Your first action should be to request an internal review from your superannuation fund or insurer. Please email them to request all documents relied upon, the policy wording, and the reasons for the decline. Most funds must provide an outcome within 45 days in accordance with ASIC timeframes. Many claims are approved at this stage once stronger evidence is submitted.

Step 2 – Gather Strong Medical and Vocational Evidence

Successful TPD claims depend on strong evidence. If denied, it is essential to obtain stronger, more detailed evidence.

Step 3 – Escalate to AFCA

If your claim remains denied after the internal review, you can escalate it to the Australian Financial Complaints Authority (AFCA). The AFCA is an independent body that can review submissions and, when the insurer has got it wrong, overturn the insurer’s decision. Note the time limits: you have two years from the internal review decision and must lodge your complaint within six years of becoming aware of the issue. AFCA reviews your case based on the information provided, may request additional details, and will facilitate a meeting to discuss settlement. If no agreement is reached, AFCA will make a written determination. The process can take six to fifteen months.

When to Instruct a TPD Lawyer

Instructing a TPD lawyer can significantly increase your chances of overturning a denial.

• Policy Interpretation Expertise: Lawyers understand complex policy definitions and can help you gather evidence to demonstrate you meet the criteria.
• Evidence Preparation: TPD lawyers know which evidence is persuasive and will ensure your claim is presented coherently, in line with your policy’s definition of TPD.
• Protection from Insurer Tactics: Dealing with insurers can be daunting. Lawyers understand how this communication works best, can challenge delays, and address unfair conclusions. It also gives you peace of mind to have an expert guiding you through this process.
• Managing Deadlines and Submissions: TPD claims involve forms, deadlines, and comprehensive evidence bundles. Lawyers manage these aspects to prevent delays or further denials.

Case Study – Murphy McCarthy v Zurich

The NSW Supreme Court clarified that “occupation” should be interpreted as the broader profession or role, not just specific tasks previously undertaken. In this case, the claimant argued that being unable to perform trench-work duties meant he could not continue as a construction manager or project supervisor. However, the Court held that difficulty with particular tasks is insufficient to prove total incapacity for the occupation as a whole. The focus should be on the ability to perform the essential functions of the broader role, even with reasonable adjustments.

Contact Garling and Co Today

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 expert support with your TPD claim or want to understand your options, contact Garling & Co today. Call us on (02) 8329 9500 for a confidential conversation or visit www.garlingandco.com.au to learn more about how we can assist with TPD claims. See our dedicated page at Garling and Co TPD Claims Guide. Start your journey to recovery today.

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?’