What to do if your TPD insurance claim is declined
If your total, permanent disability claim (TPD) is rejected, you have rights of appeal.
You can lodge an internal complaint to the insurer, or to the superannuation fund if the TPD benefit is part of your super.
The insurer has 45 days to make a decision on the complaint although a super fund has 90 days.
If the complaint is not successful, you may then be able to lodge an external complaint against the insurer to the Financial Ombudsman Service (FOS) or to the Superannuation Complaints Tribunal (SCT) against the trustee.
There are time and monetary limits on some external complaints.
Alternatively, you may be able to sue the insurer or the fund, or both, for breach of contract or trust.
Most TPD insurance rejections are based on medical evidence or cover eligibility, including not meeting the TPD definition, non-disclosure, exclusions and work capacity.
In deciding what to do in response to a rejected claim: identify the real issues in dispute; check the insurance policy wording and the law; get medical evidence consistent with the TPD definition at the date of disablement; and get medical and other evidence dealing with any eligibility issues, for example medical records about pre-existing conditions, work history and reasons for non-disclosure.