TPD benefit paid out five years after initially being denied

We assisted our client with three separate TPD claims over six years ago. The claims were based on his mental health condition, which was preventing him from being able to work. At that time, two of the claims were accepted, with one being declined in 2019.

This particular client had three active superannuation member accounts, each with a different superannuation fund. All of those member accounts held insurance cover for total and permanent disablement (“TPD”).  After we carefully reviewed each policy, it was established that he would be able to make a TPD claim against all three but it was imperative that we submitted these claims in the correct order.

One policy included a clause which stated that a TPD benefit was not payable in circumstances where an insured member had already been accepted as totally and permanently disabled by another insurer.

Due to that clause, we had to ensure that this claim was submitted and finalised first before proceeding with the other two claims.

Mental health condition that led to TPD claims

Our client was subjected to regular and ongoing workplace harassment and bullying, which caused the onset of depression and alcohol abuse.

As a result, he has not been able to work since early 2016. His mental health continued to deteriorate over time. Several doctors had differing medical opinions regarding his actual diagnosis. Those opinions ranged from an adjustment disorder through to delusional psychosis.

Our approach to appealing the insurer’s decision to deny the TPD claim

At the time this claim was denied (over six years ago), we advised our client on the prospects of having the decision reviewed. He instructed us not to appeal that decision. He continued to be unwell and was also dealing with other extremely difficult personal circumstances at that time.

When a TPD claim is denied, and you do not agree with that decision, there are options to appeal that decision. You can read more about this in our earlier blog, “What to do if your TPD or income protection claim has been rejected”.

We encouraged him to advise us if his circumstances and/or health changed so we could look at the claim again for him at a later date.

Why was this claim declined and the other two accepted?

We spent a lot of time providing the insurer with additional information and submissions regarding the medical and other evidence in support of our client satisfying the policy definition of total and permanent disablement.

That definition differed slightly from the other two policies as it used the phrase “unable ever to engage in any gainful occupation, business, profession or employment”. By comparison, the other two policies utilised the phrase “unlikely ever”.

The insurer wouldn’t accept the bundle of evidence, preferring to rely on the report of an independent specialist who examined our client in early 2019. That specialist made a comment about the possibility of our client’s condition improving at some point in the future if he commenced and stuck to an optimal treatment regime.

The insurer’s decision record acknowledged that our client was unlikely to return to work in the industry he was working in when he became unwell. Ultimately, their decision to decline his TPD claim was based on the fact that our client was 45 years of age and had another 20 years within which to receive treatment, improve his overall prognosis and then undertake occupational goals with the aim of returning to the workforce. 

The insurer could not determine that he was “unable ever to engage in any gainful occupation”.

Five years on – appeal commenced against the decision to deny the TPD claim

Despite the denied TPD claim, we remained in contact with our client every six months or so to ensure he was ok.

Fast forward five years, with a lot of things happening to our client in-between time. Our client continued to send us updated medical evidence. By the end of 2024, we had enough additional evidence which supported our original argument that even with alternative treatment, he was never going to be able to return to any form of suitable employment.

Despite the passage of such a significant period of time and a complex set of personal circumstances, we prepared the updated medical evidence and new submissions for the insurer to review their original decision.

In this particular client’s case, his original mental health condition did improve slightly, but he was never in a position to contemplate a return to the workforce on that basis. He had maintained recommended medication and treatment throughout that time.   Unfortunately, he was also diagnosed with Bipolar Affective Disorder, which further compounded his disability.

TPD claim successful with a payout of $72,000

We were successful in our pursuit of his final TPD claim after such a long time. Having reviewed the updated medical evidence, the insurer accepted the claim, and our client was paid $72,000 in TPD benefits.

Our client is now in a position where he has additional funds available to him to assist with his ongoing treatment requirements and to improve his overall quality of life.

Get help with your TPD claim

In most cases, it doesn’t matter how long ago your illness or injury prevented you from working. To be able to make a TPD claim against insurance held within super, you don’t need to hold the cover now, but you will need to have held the cover at the date that you were forced to cease working because of your ill health.

At Hall Payne Lawyers, we assist clients to determine if they have a potential claim available to them and prepare it on their behalf to ensure it has the best prospects of succeeding.

Our client’s example above shows that even in circumstances where a claim was already declined many years ago, if you have continued to be unable to work due to the same injury or illness, it may be worth seeking advice about the potential to have that decision reviewed. You will require supportive and current medical evidence to verify you meet any TPD policy definition.

Contacting Hall Payne Lawyers

You can contact us by phone or email to arrange your consultation; either face-to-face at one of our offices, by telephone or by videoconference consultation.

Phone: 1800 659 114
Email: general@hallpayne.com.au