TPD: What can be claimed, when to claim, and how many times can I claim?

What is a Total and Permanent Disability (TPD) claim?

A Total and Permanent Disability (TPD) claim typically refers to an insurance or compensation claim made by an individual who has become permanently unable to work due to a disability. This type of claim is usually associated with insurance policies, including life insurance, income protection insurance, or superannuation funds

Can I only claim TPD benefits if I am injured at work?

No! there are a number of injuries and illnesses covered under the TPD policies.

What Injuries are covered?

You could have an injury in the course of your employment, while overseas, in a public area, while paying soccer on a Sunday, and all would be covered as an “injury” under a TPD policy

What Illnesses are covered?

A number of illnesses are covered under TPD policies. For example, cancer, diabetes, stroke, heart disease and other types of terminal illness are covered by TPD policies. Most policies will cover you even if you have a pre-existing injury. However. You can check your policy to confirm your rights and entitlements.

When Can I make a TPD Claim?

Generally speaking, you should make a claim as soon as possible following your injury, illness or disease that renders you unable to work. Noting that super policies for TPD usually have a six-month waiting period. You could still make a claim under the policy until some years after the injury, illness, or disease has occurred.

How do I find out if I have TPD Insurance?

In order to determine if you have insurer benefits attached to your superannuation fund, you can start by checking your superannuation fund statement, which should provide a summary of benefits you hold with them and a rough estimate of the current amount of insurance available.
If you are looking at your superfund online, it will usually have a TPD section that says “Insurance cover” under that heading will usually have three types of cover: Death, TPD, and Income Protection.

If there is a figure next to TPD it means you have a TPD policy. If there is $0.00 or it says “not covered” it is more than likely that you have no TPD insurance, but always call your super fund to confirm. Once you have determined you have TPD insurance with your superannuation fund or private Insurer, you can consider lodging a claim or engaging a lawyer to prepare the claim carefully.

I have a Policy, so can I make a TPD Claim?

In order to access such a benefit, you will be required to make a claim against your fund and you will have to meet certain eligibility criteria along with a definition that applies to your particular situation. Some TPD funds also require you or your employer to be making the required contributions into your superannuation account. If you or your employer has not made the required contributions, you may be prevented from claiming the TPD benefit under your superannuation fund.

How do I make a Claim for TPD?

Once you have determined that you have an injury that prevents you from returning for work, and you have active TPD insurance at the time of injury you can make a claim.

How do you successfully claim TPD?

To make a claim you should follow these steps:

• Call your Superfund/TPD Insurer and notify them that you wish to make a claim for TPD benefits under your policy.
• Request the claim forms and the policy documents that were in place at the time of injury.
• Once you receive your claim form and policy documents contact a lawyer to help you fill them out.
• TPD claim forms are very important. If you fill out your claim for incorrectly or do not obtain sufficient medical evidence to support your claim your claim may be declined. For this reason, we advise that you consult an Accredited Specialist In Personal Injury Law for assistance with your TPD claim.

How to prepare for a TPD claim

1. Schedule an appointment to review the draft claim.
2. Finalise the claim form and draft letter of claim. Your legal specialist will review all your medical evidence to determine whether enough medical evidence already obtained on file would allow us to lodge your claim.
3. Additional evidence – If you do not have insurance claims, such as workers’ compensation or motor accident claims that generate many medical documents, we will consider getting medico-legal evidence supporting your claim. This may include referral to an Occupational Physician who is a specialist in determining injuries and capacity for future work.
4. Final review – Your legal specialist will collate the claim and supporting documents. You will then complete a final review, and your claim is lodged with the necessary fund.

TPD Assessment and Decision Process

1. The claim is now pending. Your legal specialist will regularly contact the fund while the claim is being processed. The Insurer will take some time to assess your claim as they need to carry out due diligence and check if you meet the necessary definition by liaising with your treatment providers, looking into your workers’ compensation or motor accident records and determining how your injuries comply with the required total and permanent disablement definition.
2. Timeframe – This can take weeks to months and, unfortunately, is totally at the Insurer’s discretion.
3. Decision Made – whether you are approved or denied your TPD benefits, they will then issue a decision to your legal provider.
4. Approved – Once successfully you will need financial advice about the taxation implications for the payment of the benefit and complete forms for your fund indicating what you wish to do with the TPD amount. Options include taking the TPD amount from your fund, combining it with your account balance under permanent incapacity provisions, or transferring the TPD amount to your account balance.
5. Claim rejected – your legal specialist will review the decision and discuss with you the options available to obtain further evidence, provide submissions or dispute the decision of the Insurer.

 How much do you get for a TPD claim?

If you have numerous superfunds you may find your TPD benefit is less than $100,000 under each policy. However, in our experience, if you have a long-term superannuation policy, or your employer has a TPD policy, the range you may receive for your TPD claim is usually between $250,000 and in excess of $1,000.000.
Any total and permanent disablement benefit is paid as a lump sum, and it is either approved or rejected by the Insurer. The amount payable accordingly to the date of disablement.

Will my TPD claim be accepted?

In our experience, most claims are accepted first go if the right evidence is submitted with the claim form and TPD benefits are paid out within 12 -18 months of receipt of the application.
The remaining claims are either rejected by the insurer of the Superfund or delayed longer that 12-18 months as the insurer does not have enough medical evidence or because there has been another claim such as a workers’ compensation or motor vehicle accident claim that relates to the injury.

What do I do if my Claim is Rejected?

You can either request a reassessment of the declined claim or if you think the decision reached by the TPD insurer is incorrect and not made in good faith or formed unreasonably you can challenge the insurers decision in Court.
You should contact a Lawyer to assist with your claim as the insurer can be very difficult to deal with and often decline claim in the hope people do not challenge the decision.

FAQ’s

Why do I need to Request the Policy Documents for a TPD claim?

• Your right to your TPD benefit depends entirely on the terms and conditions set out in the policy document that was in force at the time of your injury.
  The policy document sets out relevant information about:
  Waiting periods: How long you have to wait after your injury before you benefit becomes payable. This is usually between 6-12 month
• Approval process:How the insurer assesses your claim and what you can expect to happen. For example, the policy document will set out requirement for medical assessments, review procedures, and time frames for assessing your claim. The insurer usually takes between 6-12 months to decide on a claim for TPD benefits
• TPD definitions: This is the most important part of the policy documents. It will tell you the criteria that you will need to satisfy to classify as “TPD” and to be eligible to claim your TPD benefit

Why are TPD Definitions so Important?

TPD definitions vary from policy to policy. It is important that your lawyer reviews the definition of total permanent disablement under your policy as this will determine whether you are eligible to claim the TPD Benefit.

Most policies contain definitions that require the insured member to be unfit for employment for a number of months and unlikely to ever be able to return to gainful employment.

Examples of TPD definitions:

Example 1

• Absent from employment for six consecutive months because of sickness or injury; and
  Is so disabled at the start of those six months and continuously since that time that the Insured member is unlikely to ever engage in any reasonably suitable occupation

Put simply, this definition means that you must not be able to work for the first six months following your injury and it does not appear that you will ever return to suitable employment in the future.

Example 2

• The insured member is unable to perform, in respect of the first two years of disability, at least one income producing duty of their regular occupation
  The important duties of any gainful occupation for which you are reasonably suited by way of education, training, or experience
  Are not working in any undertaking usually performed for wage of profit
  Are under the regular care, and following the advice and treatment of a Medical Practitioner

This example is far more complex, unfortunately definitions under TPD policies are beginning to become more complex and have more elements that need to be satisfied to try and minimise the amount of TPD benefits paid out.

Example two requires the policy holder to be unfit for at lease one aspect of their usual job in the first two years, and following that, in order to be eligible the condition must deteriorate to the extent that the policy holder can no longer perform “important duties” of their gainful employment.

The second example also brings in training and education component. Which means that if you can be retrained in any other type of employment and you would be able to undertake that employment you will not be TPD.

In effect to satisfy this definition you must not be able to work and never be able to work in any form of employment ever again. Often there are a number of vague terms in the definitions such as “important duties” or “one income producing duty” which are difficult to understand. Where these terms aren’t defined it is up to interpretation which can make claiming a TPD benefit very difficult. For this reason, it is advised to contact a lawyer who knows and understands TPD claims and the insurer framework.

How do I fill out my TPD Forms?

The TPD insurer will send you out forms to complete. You will need to complete the following:

• Application for TPD: You will need to include information about your injury or illness, details of your incapacity to work, your medical history, employment history, and financial history.
• Doctors Statement x 2: Your treatment general practitioner who you have seen for your injury/illness will need to complete a form detailing the nature and extent of your injury/illness. They will also need to provide their opinion as to whether you will ever work again. The other Doctors Statement will need to be completed by another doctor, you can use either a specialist, another general practitioner, or any other doctor you have consulted for you injury/illness
• Certified proof of identity: You will need to provide certified copies of your driver licence, passport, or birth certificate.
• Medical evidence: Your claim for TPD must be accompanied by medical evidence supporting your claim that you are totally and permanently disabled.

What Medical Evidence do I need to Provide in a TPD claim?

The medical evidence that you will need to provide depends entirely on your injury or illness.

For example, if you are unable to work due to a workplace injury and you have made a workers’ compensation claim for whole person impairment, you can provide the medical evidence to the TPD insurer as it will prove that you have a whole person impairment and will address your ongoing incapacity and your inability to work.

If you have a longstanding illness you will need to provide evidence detailing the treatment received. It will also be beneficial to obtain a detailed report addressing your restrictions and provide detailed reasons as to why you can no longer undertake aspects of your gainful employment.

Will I be Medically Assessed in my TPD claim?

The insurer will have you assessed if they think you may not satisfy the TPD definition.

In our experience, if the right medical evidence is provided with your application it will be difficult for the insurer to dispute your work capacity and they may approve your claim without the need for a medical assessment.

If the insurer decides to have you assessed they will likely have you assessed for the purposes of obtaining an employability assessment report or they will have you assessed by an occupational physician to see if you are able to undertake your employment as per the definition of TPD.

Should you have any further questions, please contact our office at (02) 8329 9500 or complete a free case assessment here.