What to do if your TPD claim is rejected

It’s unfortunately all too common for Australians to be declined on their TPD claims. Recent research found that over 10% of finalised claims for TPD initially come back declined.

Thankfully though, being declined on a TPD claim isn’t necessarily the end of the road. With the right support and steps in place, it’s often possible to either reverse their decision, or at least achieve a separate positive outcome

We’ll walk you through what you can do if you’ve been declined, and show how the team at Shine Lawyers can help you access the support you deserve.

Why do insurers deny TPD claims, and can those decisions be challenged?

This isn’t a complete list, but a majority of TPD claims are declined because:

• a payment (or multiple payments) hadn’t been made on time and the insurer considered the policy ‘lapsed’

• the specific type of injury or illness wasn’t one of their listed conditions, or they had a specific exclusion for the injury/illness you made a claim for

• the person making the claim had a pre-existing condition they didn’t tell the insurer, and the insurer believes it contributed to them not being able to work anymore.

As much as insurers will always advertise that they’re there for you, at the end of the day, they’re businesses. They make money from policy payments and lose money from paying out claims. So if they can find the most minor of technicalities, more often than not, insurers will use them to deny a claim. Even if that ‘technicality’ denies someone much-needed care and resources as they face the toughest and most stressful life challenges they’ve ever faced.

But the big thing to remember is that these decisions aren’t set in stone, and you can challenge them. In fact, recent insurance data shows that over 66% of disputes made on TPD claims either result in something like a settlement agreement, or the decision being entirely overturned.

Steps for handling a denied TPD claim

Step 1: Decide if you want to proceed yourself or not

There’s no doubt it’s a terrifying and intimidating obstacle, being declined on a claim. And having this challenge thrown into the mix while you’re navigating other serious challenges in life like an injury, illness or medical condition is incredibly unfair.

If you feel ready to take steps yourself, there are ways you can challenge and dispute the decision yourself. But if you need someone in your corner who can absorb as much of the mental load as possible, the team at Shine Lawyers can do everything we can to get you the best possible outcome.

We’ll assemble the strongest case possible and liaise with the insurer directly to get a favourable outcome for you. But, on the very rare occasion that an agreement isn’t reached, we’re ready and capable of seeing your case through the courts.

And we’ll do it all on a No Win No Fee* basis, so if we don’t win your case, you won’t pay any legal fees.

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Step 2: Challenge the decision via an internal dispute/complaint

Insurers have very strict requirements if they receive a formal complaint or you dispute their decision. You usually have 28 days from receiving your rejection letter to submit your appeal or complaint. But if they receive it in that window, they need to respond in very set windows (often 30 days) or they risk having their decision overturned by the regulators.

Step 3: Challenge the decision via an external dispute/complaint

If you’ve tried working directly with the insurer and the decision didn’t change, you have the option of escalating the matter to the Australian Financial Complaints Authority (AFCA). AFCA are completely independent, and they’ll examine the evidence you bring forward along with the decision the insurers made and often decide themselves on a fair outcome.

This is often where it’s important to have your case built as well as possible, factoring in precedents and evidence, to ensure this step has the best chance possible of a positive result.

Step 4: Extra legal steps and endeavours

If dispute resolution through AFCA didn’t achieve the result you wanted, it’s still not impossible to receive compensation. But this is where seeking legal advice is probably the best way to go. Your remaining options will involve:

• Mediation – It’s not uncommon for a matter to proceed to a mediation in the court phase and before a trial.

• A new claim – If the circumstances have worsened significantly since the initial claim, and it doesn’t conflict with why you were originally declined, it’s technically possible to send another claim through.

• Court – If settlement discussions and mediation don’t go the way you’d hoped, and it doesn’t seem worthwhile to submit a new claim, the last stop is to go via the courts.

Shine Lawyers – we’re here to help

The Shine Lawyers’ Superannuation and Disability Insurance team have years of experience in successfully helping clients through the TPD insurance claim process and achieving the outcomes they deserve.

The legal journey can be complex, but our expert team will guide you through each step of the process and help you to understand your rights. We’ll do the hard work on your behalf so you can focus on your recovery, and will strive to resolve your case as quickly as possible.

Learn more about our client Dudley’s success story with Shine Lawyers and how we helped him get his life back on track: