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Across Australia, thousands of people are paying for TPD insurance through the hard earned money in their super funds. Many people are unaware they even have TPD insurance. However, if you suffer from an injury or illness that means you are unable to work, finding out that it is available and that you may be eligible to claim a lump sum can come as a great relief. However, this relief may be short-lived if your insurer rejects your TPD claim. If you have a chronic illness or have sustained a serious workplace injury, rejection of your claim can add worry and stress to an already difficult situation, particularly after you’ve already participated in the insurers’ claims process in good faith. The important thing for you to know is that you have options – you don’t have to simply accept the rejection. This blog provides practical information on what to do next
You can – but insurers are not there to represent your interests. They won’t always tell you what you need to know – when you need to know it. That’s why Littles strongly recommends getting high quality legal advice early. When is the right time to do this? We say:
· if you’re working and struggling because of injury or illness and considering stopping work, or
· you’re working and struggling because of illness or injury and considering reducing the number of hours you work, and/or
· if you’ve already stopped work as a result of illness or injury, as soon as possible!
Even if your insurance policy or super fund rules don’t prescribe time limits or otherwise preclude late claims, it’s generally the case that the sooner you make your claim, the stronger it will be. Why is this? Well, for example:
· medical and employment records may be lost, or much more difficult to access, and
· your memory fades over time and you may forget important details.
These and other factors make it harder to make a strong claim that your illness or injury was the reason you ceased work.
You are entitled to appeal the rejected claim to the original decision-maker – an employee of the insurer – directly. All super funds and insurers have a process for handling internal appeals and some even have whole departments set up to deal with these complaints.
If you make a complaint relating to a decision of a superannuation fund, they must respond within 45 days.
If the complaint relates to a decision of an insurer alone, they must respond within 30 days.
If directly engaging with the super fund or insurer doesn’t work, it’s often worth to appeal to the Australian Financial Complaints Authority (AFCA).
The rules for making an AFCA claim vary depending on whether you are making a claim against a super fund or insurer. However, the processes are largely the same:
· a case manager will be assigned and documents and submissions will be exchanged between the parties
· there is usually a conciliation conference
· if the conciliation conference doesn’t resolve the complaint, the case manager usually delivers a recommendation about the outcome that they think is fair and reasonable under the relevant law, and
· the recommendation is binding if both/all parties to the complaint accept it.
If you aren’t happy with the recommendation, the complaint will proceed to a final determination which is delivered by an ombudsman.
You can commence litigation in relation to a rejected insurance claim involving an insurer alone or involving both an insurer and a superannuation fund.
While the exact process will depend on which state or territory you commence your claim, the processes are similar:
· a statement of claim or some other formal document is lodged with the court to start the claim (sometimes also called a proceeding)
· the insurer and/or superannuation fund must then usually lodge a response or defence to the statement of claim
· the parties will then usually exchange all of the documents which they have which are relevant to the claim
· parties will usually get and exchange the expert and medical evidence which they rely on to support their claim and a mediation is usually held sometime after this
· if the matter doesn’t settle at mediation, the matter will proceed to a full court hearing.
Read more here: Total and Permanent Disability Claims – Littles
Littles are experts at investigating, managing and settling insurance claims. Our staff have decades of experience in the superannuation and insurance industries, and know how to best prepare and prosecute your claim with a high success rate.
However, there may be strict time limits to bring legal action against an insurer if your claim has been declined.
Do you have an injury or illness that prevents you from working, or just want to know more about what insurance you have under your super? Get in touch with Littles for a free super claims check. We can help you understand what you’re entitled to. Know where you stand, and get peace of mind.
Not only do we offer a FREE claims check – we handle most insurance claims on a no win, no fee basis. Our Head of TPD and General Insurance, Rowan McDonald, is an insurance law expert. If you think you might have a claim, get in touch with Rowan and his team for high quality legal advice.
Please note that this information is intended to provide general guidance only. You should not act or refrain from acting on the basis of such information. Appropriate professional advice should be sought based upon your individual circumstances. For further information, please contact Littles.