TPD Claim Rejected

A rejected Total and Permanent Disability (TPD) claim can feel overwhelming, especially when you rely on that lump sum payment to cover medical expenses, support your family, or safeguard your financial future. Many people experiencing permanent disability or ongoing injury or illness invest months, even years into the TPD claim process, only to receive a rejection letter from their insurer’s internal dispute resolution department or superannuation fund. This complex process can be time-consuming and emotionally draining, but it does not have to be the end of the road.

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A rejected TPD claim often leaves people uncertain about their legal options, strict time limits, and potential for a successful appeal. Whether you are dealing with mental health conditions or a severe physical disability, you deserve to understand your rights under your insurance and superannuation policy. Below, we look at common reasons a TPD claim becomes rejected, what you can do if your claim has been rejected, and how to seek legal advice or urgent legal advice for a potential turnaround.

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Reasons Your TPD Claim May Be Rejected

A TPD insurance claim can be declined for a variety of common reasons. Understanding these issues can help you make an informed decision about your next steps.

The Claim Does Not Meet the Insurer’s Definition of Total Permanent Disability (TPD)

Each insurance policy or superannuation policy has its definition of total and permanent disability. Some policies assess whether you can work in your same capacity, while others look at whether you can perform any occupation at all. If your rejected claim falls short of the criteria, such as needing to prove you cannot return to work in “any” role rather than “your usual” role, your denied TPD claim may hinge on an interpretation issue.

Seek urgent legal advice: A specialised TPD lawyer can review your relevant policy documents and help argue that you meet the total permanent disability requirements.
Insurer’s internal dispute resolution: If a policy’s definition is ambiguous, a lawyer can assist in preparing a written complaint or official complaint. This may involve an internal review or even escalating to the court system if necessary.

Insufficient Evidence or Evidence Provided Isn’t Accurate or Complete

Insufficient evidence is one of the most common reasons for a denied claim. Medical evidence, such as medical records or specialist reports, must demonstrate that you cannot return to work. This is especially true for disability insurance claims related to mental health, including mental illness or bipolar disorder.

Relevant documents: You need comprehensive proof of your functional limitations, including doctors’ letters, specialist opinions, test results, and a detailed account of how your condition prevents you from working.
Minimum waiting periods: Some superannuation provider or insurer policies require a minimum waiting period before lodging a TPD claim. Missing these deadlines can lead to an automatically rejected TPD.
Income protection: If you have separate income protection coverage, make sure those claim details do not conflict with your TPD statement of facts.

The Insurer’s Assessment Finds That the Insured Can Work in Some Capacity

Often, insurers use independent assessments to argue you can still perform a job in some capacity. For instance, if you’ve been a labourer all your life but can now only manage desk-based work, the insurer might conclude you can hold “some” position—leading to a TPD claim rejected decision.

Insurance company’s decision: They may claim you are “fit for alternative employment” rather than fully disabled.
Court proceedings: If you feel the assessment is incorrect or unfair, seek legal advice and consider whether you need to file a formal complaint through the Australian Financial Complaints Authority (AFCA), the Financial Ombudsman Service, or an external review.
Professional advice: A TPD lawyer can guide you, gather additional medical evidence, and counter any erroneous findings in the insurer’s assessment.

Were You Provided with the Right Medical Information and Reports?

In many insurance claims, crucial medical records or specialist reports may be overlooked, incomplete, or incorrectly stated. This shortage of accurate information leads to a claim that has been rejected more often than you might think.

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Ensure you gather all relevant documents from each treating professional, highlighting your inability to resume work in any reasonable capacity.
If you have mental health conditions, emphasise consistent counselling or psychiatric treatment to illustrate the genuine impact on your daily life.
If your rejection letter suggests that you have not provided enough detail, an internal review can be requested, supported by new medical or allied health reports.

Has the Correct Definition Been Applied in Your Claim?

Sometimes, an insurance company’s decision hinges on misapplying the insurance and superannuation policy definition of permanent disability TPD. Definitions might vary between “own occupation” vs. “any occupation.” If the insurer used the wrong standard, you have grounds to appeal a rejected TPD verdict.

Check if your super fund or superannuation provider is using the correct policy documents.
Consider hiring a specialist TPD lawyer on a no-fee basis (often known as “no win, no fee”) to interpret these definitions and challenge the insurer if necessary.

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What to Do if Your TPD Insurance Claim Is Declined

When your TPD insurance claim is turned down, your next steps might involve an internal review, filing a written complaint with the Financial Complaints Authority AFCA, and taking the matter up with the Ombudsman. If these measures fail, you might have to consider the court system.

Seek urgent legal advice: Engage a TPD lawyer who can handle the appeals process. Having experienced guidance can be vital in navigating strict time limits and complex legal documents.
External review: If the internal dispute resolution process does not bring a successful claim, you can request an external review through AFCA, where an independent body will assess your case.

Forcing the Superannuation Fund Onto the Negotiating Table

When all internal options have been exhausted, further action may be needed to prompt your superannuation fund to negotiate.

Formal complaint: Submitting an official complaint to an external body can encourage your fund to revisit the rejected TPD claim.
Court proceedings: In extreme cases, a lawsuit may be the only path. This can be time-consuming, so weigh the potential outcome against legal costs, though many claimants opt for a no-fee basis arrangement with their lawyer.: Submitting an official complaint to an external body can encourage your fund to revisit the rejected TPD claim.

Walking Away with Part of Your Benefit Is Better Than Nothing

If an insurance company’s decision doesn’t fully align with your request, sometimes it’s possible to negotiate a partial TPD benefit. This approach can still provide critical financial support for medical expenses, daily living costs, or other obligations.

Informed decision: Accepting a partial payout may still be beneficial if full acceptance is unlikely.
Permanent disability coverage can be complicated: So talk with a TPD lawyer about whether a partial settlement is worthwhile or if you should pursue a successful appeal.

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Get Help from TPD Helpline

When your TPD claim is in jeopardy, or if your claim has been rejected, professional guidance can make all the difference. At TPD Helpline, we understand how complex the claims process can be, especially if you’re dealing with mental illness, severe physical injury, or other debilitating conditions. We connect you with knowledgeable professionals who can interpret insurance policy language, compile comprehensive medical evidence, and handle negotiations on your behalf.

TPD Helpline Australia can be contacted on 1300 679 222. Our helpline reps are well-versed in all things related to TPD claims, injury compensation claims, health conditions, illnesses and injuries whether sustained at work or not. If there is an issue we can’t answer over the phone, we have access to a mountain of resources so that we can call you back within the day to provide answers.