TPD claim rejected? What to do next
A rejected TPD claim is often not the end of the matter. Many rejected claims are later paid on review. Here is how the review process works, explained in plain English.
A rejected TPD claim is often not the end of the matter. Many rejected claims are later paid, either through the review process inside the super fund, through the Australian Financial Complaints Authority, or in court. What matters now is finding out exactly why your claim was rejected, protecting your time limits, and putting the right evidence in front of the right decision maker.
This article explains each step. If you have not read it yet, our short guide to what a TPD claim is covers the basics.
First, find out why the claim was rejected
You are entitled to written reasons. If the letter you received does not clearly explain the decision, write to the fund and ask for the reasons and for copies of the material the insurer relied on, including any medical reports it obtained about you.
You should also ask for the policy document and the fund rules that applied to your cover. The single most important thing in any TPD claim is the definition of total and permanent disability in that document. Claims are won and lost on how the evidence lines up against those exact words, not against what anyone assumes the words mean.
The common reasons claims are rejected
| Reason given | What it usually means |
|---|---|
| The definition was not met | The insurer says you could still do some work you are suited to by your education, training or experience |
| Not enough medical evidence | The reports do not clearly answer the questions the policy wording asks |
| The cover conditions were not met | The insurer says your cover had lapsed, or you were not working the required hours when the cover was tested |
| Something was not disclosed | The insurer says your application left out part of your health history |
| An exclusion applied | The policy carves out your condition or the circumstances of your claim |
Each of these can be challenged. Insurers apply the strictest reading of the policy that the words allow. A review often succeeds by showing that the correct reading, applied to better evidence, comes out the other way.
Step one: gather your documents
Before any challenge, collect the rejection letter and reasons, the policy document, the medical reports the insurer relied on, and your own treating doctors’ records. If you have changed jobs over the years you may also have cover in more than one fund, and each fund is a separate claim. Our note on claiming with multiple super funds explains this.
Step two: the internal review
Every fund must have an internal dispute resolution process. You lodge a complaint with the trustee setting out why the decision is wrong and enclosing any new evidence, such as a further report from your treating specialist that answers the policy wording directly. The trustee must deal with your complaint within strict timeframes set by the regulator.
This step is not a formality. A well prepared internal complaint, aimed at the exact reason for the rejection, resolves many claims without going any further.
Step three: the Australian Financial Complaints Authority
If the internal review fails, you can complain to the Australian Financial Complaints Authority, known as AFCA. It is free, it is independent, and it has the power to substitute its own decision for the decision of the trustee or insurer.
Be careful with time here. Strict time limits apply to AFCA complaints, and in superannuation disability cases the complaint must generally be lodged within a certain time frame after the final decision on your internal complaint. Waiting costs people real claims. If you are anywhere near a deadline, get advice immediately.
Step four: court
Where AFCA does not resolve the matter, court proceedings against the trustee or insurer remain available. Court has its own limitation periods and its own costs risks, and it is the last resort rather than the first. It is also the step where having your evidence in order from the beginning pays off most.
Three things not to do
- Do not treat the first decision as final. It is one insurer’s reading of one set of evidence, nothing more.
- Do not withdraw your super balance or close the account before getting advice. Doing so can complicate your claim.
- Do not sit on it. Every step above has a clock attached, and some of them are short.
What to do next
Read the rejection letter, gather what you have, and get a straight answer on whether the decision can be challenged. We act on rejected and disputed TPD claims across every Australian state and territory, on a no win, no fee basis, and we will tell you plainly if we think a challenge is not worth running. The quickest way to start is the entitlement check, or send us an enquiry with a copy of the rejection letter.
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