Total and Permanent Disability (TPD) claims can be particularly complicated claims to make.
Usually the complexity arises from the terms of the policy – TPD policies can vary greatly in their definitions and eligibility requirements for making a claim, some requiring an enormous level of detail relating to your health, medical history, work history, lifestyle, and when and how you sustained the injury or illness which is the basis for the claim.
In other situations, the difficulty occurs because the claim is made through the TPD coverage held within your superannuation fund, or because you have also made a workers’ compensation or motor vehicle accident compensation claim as a result of your injury.
Whichever circumstance applies to you, embarking on a TPD claim without good advice and guidance from legal professionals with expertise in this area of compensation law is a particularly perilous assignment.
Large insurers have the experience and resources to challenge the claim of a person without legal representation. They can do this by questioning medical evidence, by suggesting other causes for your injury, by insisting on lengthy waiting periods until your injury stabilises and many other methods which can greatly extend the time it takes for your claim to be decided, causing you extreme stress in the process. What do you do if they eventually decline your claim?
Why TPD claims are complex
Deep in the detail of TPD policies are very precise pre-conditions a claimant needs to meet before their claim can be accepted. One of the most common distinctions in TPD policies is between ‘own’ and ‘any’ occupation clauses. It’s important to know whether your policy makes this distinction. Own occupation policies cover the situation where you are declared unfit to perform the job you had, or for which you are suited because of your education, training and experience. Any occupation policies are harder to satisfy in that you must show you are unfit to be employed in any job for which your training, education and experience would otherwise make you suitable.
It should be noted that super funds can only offer ‘any occupation’ TPD cover to fund members, with the member responsible for any portion of the policy which is ‘own occupation’. The super fund owns the TPD policy and can make changes to its definitions and payment terms when it chooses. Again, the advice of a TPD specialist lawyer is advised if this occurs within your super fund.
Making the claim
One of the main advantages of having an experienced TPD lawyer in your corner when making this type of claim is the complexity of TPD claim forms.
These forms will ask for a lot of information from the claimant and many people become confused about whether they are either providing too much information, or not enough. Some parts of the form may ask for a ‘yes’ or ‘no’ answer when in fact, you need to provide more information than those answers allow. An expert lawyer will make the form-filling process much easier than if you do it yourself.
Medical evidence is a key part of any TPD claim, with a medical certificate usually required to be submitted with the claim. It is essential that the medical specialist who examines you has the correct details about how you sustained your illness and injury, as well as any prior conditions or ailments you may have. Earlier injuries may be relevant to how you sustained the injury which has stopped you working and should not be kept from the insurer, as they may be used to challenge the validity of your claim.
A good TPD lawyer, in particular, can be invaluable in ensuring the medical evidence in support of your claim addresses the definitions and other criteria detailed in the TPD policy. This may require eliciting a more detailed statement or opinion from the medical examiner.
Your lawyer will also gather other evidence to support your claim, such as a statement from your previous employer and evidence about why you are unfit for other types of work.
Persistence pays off
One of the most frustrating experiences for those who make a TPD claim is to see it submitted to the insurer and then watch it progress at a snail’s pace. Nothing may be heard back for weeks or months and then suddenly, the insurer asks for another piece of evidence or information to support the claim. In the meantime, the claim may pass through the hands of multiple claims officers as one leaves and another starts.
Finally, the insurer may decline your claim. They will usually provide reasons but if you’ve already waited a year or more for a resolution, this experience can be infuriating.
By having BPC Lawyers acting for you in this claim, we take on the unpleasant work of persisting with the insurer to resolve your claim promptly and efficiently. We also know what to do if your claim is initially unsuccessful, which does not mean it is doomed for all time. Avenues such as formal dispute resolution and, ultimately, court action if necessary, are available if your claim is denied.
If you’re in the situation where you need to make a claim on your TPD policy, contact Sydney Personal injury Lawyers today for an initial case assessment.