A total and permanent disability claim declined over a date, and the records that changed it

An insurer declined a TPD claim. Its reason was timing. On the evidence it had, the woman became disabled after her insurance cover had ended. Her superannuation (super) fund reviewed that decision and agreed with it.

The evidence that changed this already existed. It was spread across years of medical records and several providers. Once it was found and put forward, the claim was reviewed again. It was accepted and paid.

A specialist firm handled this matter. ClaimGuide introduces people to firms that handle claims like this one. Names and identifying details have been removed or generalised.

What the insurer decided

The insurer said she did not meet the criteria for payment. Its view was that she met the TPD definition years after her cover had ended. On that basis, no benefit was payable.

The fund's trustee (the company that runs the fund) then looked at the insurer's position. It found no basis to ask the insurer to reconsider.

So two organisations had said no. Most people would read that as the end of it.

Why the date mattered

In a TPD claim, showing that someone is disabled now is not always enough. The insurer may also look at:

• when the person became disabled
• when a doctor certified it
• whether they held cover at that time

In this matter, the decision turned on the last point. The insurer used a certification date that fell after her cover ended.

This account doesn't say why her cover ended. Cover inside super can stop for a few different reasons. This guide explains how insurance inside super works, including how cover can end.

The records were there, but scattered

The problem was not a lack of medical evidence. The right records had not yet been found, gathered and put in front of the insurer.

Her work had involved a lot of travel across regional and remote areas. Over many years, she saw different providers in different places. No single file held the whole story.

So the insurer had been deciding on part of the picture.

What the firm did

The firm went back through years of medical history. It found, requested and reviewed records from several providers, including a community health service.

It kept to one question. Did her medical history show the disability had developed while she still held cover?

The evidence put forward included:

• older medical records showing how her conditions started and progressed
• evidence of serious physical and psychological health conditions
• evidence from her general practitioner (GP) about when the disability began
• Services Australia material showing how her conditions affected her day to day, including her acceptance onto the Disability Support Pension (DSP)
• her work and treatment history, which explained why the records were spread out

Together, these showed her conditions were not sudden. They had a history and a progression. They were already affecting her capacity to work before the certification date the insurer had used.

A note on DSP. Being granted DSP does not decide a TPD claim. Different test, different decision maker. But the records behind a DSP grant can be relevant to a TPD claim. More on that in what your super may hold if you're on DSP.

The review the firm asked for

The firm did not simply ask the insurer to take another look. It challenged the basis of the decision. It:

1. asked for a full review of the declined claim
2. asked the insurer to reassess when the disability began
3. asked the fund to consider the new medical and functional evidence
4. asked for a copy of a medical report the insurer had relied on, which had been requested before and not provided

That changed the question. It moved from "when was she certified?" to "when does the evidence show she became totally and permanently disabled?"

The outcome

The claim was accepted. She was paid a TPD benefit of $315,000.

Every policy and every claim is different. One outcome says nothing about what another claim is worth.

The matter was resolved at the review stage. The claim changed because the evidence in front of the insurer changed.

What this one matter shows

• A decline is a decision on the evidence the insurer had at the time.
• The question is not always whether someone is disabled. Sometimes it is when.
• The records that matter can sit with old doctors, community health services, hospitals, specialists or government agencies a person no longer deals with.
• Finding them takes time and energy. Many people are too unwell or too worn out to track them all down alone.

Most people don't know a decision can turn on a date, or that records from years ago can change it.

What this matter does not show is that any other declined claim will be paid, or what any claim is worth.

If a claim has been declined

Some things that mattered here are worth knowing in general:

• Read the reason closely. Here, the reason was about timing. That pointed straight to the evidence that was missing.
• Ask what the decision relied on. In this matter, the firm asked for a medical report the insurer had used but not shared.
• New evidence can be put forward. A trustee that has accepted the insurer's view can still be asked to consider whether new evidence changes the outcome.
• There is an outside body. If the fund's own complaints process doesn't resolve things, the Australian Financial Complaints Authority (AFCA) is the free, external body for super and insurance complaints.

For more, see My insurance claim was declined. What now? If a claim hasn't been declined but has gone quiet, this guide covers claims that stop moving.

ClaimGuide does not run claims or assess anyone's entitlements. We explain how the system works, in plain English, and connect people with specialist firms when that would help.

If you'd like to talk a declined claim through, get in touch. You never pay us. Panel firms do.

Sources

• The record for this story is the specialist firm's matter file, held with the person's consent. Names and identifying details have been removed or generalised.
• General background on DSP and on how cover inside super can end comes from The Guide pages linked above.