A roster that changed every week: how one word in the policy decided a $140,400 claim

A hospitality worker's TPD claim came down to one word in his policy: "regular". The insurer was moving towards declining the claim. A specialist firm answered the insurer's reading of that word, and the insurer then paid the claim in full: $140,400.

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

This is a case story from one real, finished matter. A specialist firm handled it, not ClaimGuide. We introduce people to firms that handle claims like this one. Names and identifying details have been left out.

Where he started

He had not been able to work for years. He needed money for treatment and rehabilitation. He needed to keep paying rent.

He did not know his superannuation (super) might include insurance. That is common, not careless.

It did. He had TPD cover through a major super fund, under a group policy: one insurance policy the fund takes out to cover many of its members. If you are not sure what cover sits in your own super, this guide explains how to find out.

The word the insurer focused on

A TPD policy does not only look at your health. It can also look at how you were working before you stopped.

In this matter, the sticking point was the policy's employment definition. The insurer accepted that he had been employed for at least 12 months. It accepted that he had worked more than 15 hours a week during the relevant period.

What it did not accept was that he worked a "regular number of hours each week".

He worked in hospitality. His hours were not the same every week. His roster changed. Some weeks were busy and some were quiet. There was overtime. There were seasonal changes. There was one lower week over Christmas and New Year.

The insurer's preliminary view was that this was not a regular number of hours. On that reading, it would assess him under a stricter part of the same policy. That test would have been much harder to meet. It could have meant no payment at all.

Regular does not mean identical

The firm's answer was simple. Regular hours do not have to be identical hours.

A person can have a regular pattern of work even when the roster changes from week to week. In hospitality, changing shifts, overtime, seasonal demand and leave are normal. Someone can have steady, ongoing work and still work different hours each week.

The firm argued that the policy did not ask for the same hours every week. It asked for a regular pattern of work.

It pointed to two kinds of evidence:

• the insurer's own information, which showed he had generally worked well above the 15-hour threshold
• earnings records showing steady income from the same employer over several financial years

Together, the firm said, these showed stable, ongoing work. Not irregular or random work.

What the firm put to the insurer

The firm argued that:

• hospitality workers often have changing rosters
• overtime and seasonal changes do not make work irregular
• one lower week should not outweigh an otherwise consistent pattern
• he had worked above the policy's 15-hour threshold
• the insurer had already accepted he had been employed for at least 12 months
• steady earnings over several years supported a regular pattern of work

It asked the insurer to reconsider, and to assess him under the part of the TPD definition the firm said applied.

The claim was then paid in full.

A delay that was not his

There was a second problem in this matter, and it sat on the fund's side.

A procedural fairness letter sets out what an insurer is thinking of deciding, and gives the person a chance to respond before a final decision. In this matter, the letter was dated weeks before it was passed on to the firm. The fund later apologised for the oversight and confirmed a new date to respond by.

People making a claim are often expected to respond within strict timeframes. Delays and mistakes can happen inside the claims process too. When you are unwell and short of money, that is a lot to keep track of. Watching the dates, and checking the insurer has the right information, is part of what a specialist firm does.

If a claim has gone quiet rather than wrong, when a claim stops moving explains what the regulators' own data shows about claims that stall.

What a policy definition can turn on

A TPD claim is not always decided on medical evidence alone. Sometimes it turns on how a definition is worded. Sometimes it turns on how the insurer reads one phrase. Sometimes it turns on which part of the policy is applied at all.

These are some of the things a definition like this one can turn on:

• how the policy counts regular hours, and whether a changing roster fits
• any minimum hours, like the 15 hours a week in this policy
• how long someone had been employed before they stopped work
• the period the insurer looks at when it tests work history
• which part of the TPD definition the insurer applies
• records that show a pattern of work, like earnings over several years

Policies word these things differently. Our guide to TPD cover in super explains the main types of definition in plain English.

What this story does and does not tell you

This story shows how much the wording of a policy can matter. It does not tell you anything about your own policy, or what your own claim might be worth.

A preliminary view is not the same as a final decision. If an insurer has raised a concern, or a claim has been declined, this page sets out the review pathways that exist.

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 want to talk it through, get in touch. You never pay us. Panel firms do.

Sources

• The record for this story is the specialist firm's matter file for one real, finished TPD matter, held with consent. Names and identifying details are left out.
• No public sources were used for the facts of this matter. For general background on TPD cover, see TPD cover in your super.