TPD claims for fibromyalgia and chronic pain

You can claim total and permanent disability (TPD) cover through your super if fibromyalgia or chronic pain has stopped you from working, but the claim must meet the definition in your policy. The challenge is that these conditions often have no single test and few visible signs, so the evidence has to show clearly how the condition limits what you can do and why that is unlikely to change.

This article is general information, not advice on your own situation. It does not predict whether any claim will succeed or what it might be worth.

Why these conditions raise particular questions

Fibromyalgia and other chronic pain conditions are usually diagnosed by a specialist from a pattern of symptoms, such as widespread pain, fatigue, poor sleep and difficulty concentrating. There is generally no scan or blood test that proves the diagnosis or measures severity.

A TPD definition does not ask whether you have a diagnosis. It asks whether you are unlikely ever to return to work of the kind the policy describes. Because the condition depends heavily on what you report, an insurer will look closely at whether your account is consistent and supported by the people treating you.

The definition in your policy comes first

Every policy sets its own test. Read the wording before anything else, because it shapes what evidence matters. Our glossary entry on own occupation and any occupation explains the two common approaches.

Type of test	What it generally asks
Own occupation	Whether you are unlikely ever to return to the job you were doing before you stopped
Any occupation	Whether you are unlikely ever to work in any role suited to your education, training or experience
Activities of daily living	Whether you are unable to manage certain everyday tasks without help

Some policies use one test, some use several, and the test can change with your age, hours of work or employment status when you stopped. Our overview of what a TPD claim is sets out the general framework. If you hold cover in more than one fund, read our note on multiple super funds and TPD first.

Where a policy uses a daily living test, the glossary entry on activities of daily living explains what that usually involves.

How insurers approach symptom based conditions

Insurers generally ask two questions. First, has the condition kept you from working for the period the policy requires? Second, taking into account reasonable treatment, are you unlikely ever to return to the relevant work? Sometimes, they may also require you to have followed the advice of a medical practitioner or exhausted all treatment options. It all depends on the particular policy you are assessed under.

For fibromyalgia and chronic pain, an insurer will often look for these things:

• A diagnosis made or confirmed by a suitable specialist, such as a rheumatologist or pain medicine specialist.
• A treatment history showing you have followed reasonable medical advice, including medication, physiotherapy or pain management programs.
• Evidence of how the condition affects sitting, standing, concentration, sleep and reliability at work.
• A steady record over time, rather than a short window of treatment.

Gaps in treatment can be read as a sign that the condition is improving or is not serious, so explain them honestly if they exist.

The evidence that tends to matter

Reports from your treating specialist usually carry the most weight. A helpful report goes beyond the diagnosis and addresses your functional capacity: how long you can sit or stand, how well you can concentrate, how pain and fatigue affect an ordinary working day, and what the outlook is. Your GP, physiotherapist, psychologist or occupational therapist can add detail.

Your work history is just as important. Records of reduced hours, changed duties, sick leave and any attempt to return show how the condition has affected you in practice. Keep notes on your daily activities too, because they help show what you can and cannot sustain.

Be consistent. What you write on the claim form should match what your doctors have recorded, what your employer knows and what you tell any examiner. Insurers read all of it together.

Common sticking points

A claim can stall where the medical evidence describes the diagnosis but not the effect on work, where treatment has been sporadic, or where the file shows activity that seems at odds with the claimed limits. An insurer may also arrange its own medical examination. Our guide on the TPD claim process walks through the stages, and if a claim is declined, our article on what to do when a TPD claim is rejected explains the options.

Time matters. Evidence becomes harder to gather as years pass, and strict timeframes set by the regulator and the Australian Financial Complaints Authority apply to complaints. Court time limits can also apply. Read our guide to time limits and seek advice promptly.

Money questions that follow a claim

If a claim is paid, questions about tax, Centrelink, child support or withdrawing money from super can arise. Those questions come out of the claim, but the answers depend on your own circumstances and belong with your accountant or financial adviser. We give legal advice, not tax or financial advice.

What to do next

Make sure each of your treating doctors has a full and consistent picture of how your symptoms affect your daily life and your ability to work. Keep copies of your reports, your work records and your policy documents. You can then use our claim check to see where you stand, or contact us and we can look into your super, locate your insurance policies and review their terms for you.