How to make a claim
Each policy will have different requirements dependent on the definitions contained in the policy documents.
In most cases, there are detailed forms that need to be completed by you, as well as other forms and reports that will need to be completed by your treating doctors. Often, the insurer will also require you to undergo an independent medical examination to determine your level of fitness for work.
It is important to seek early legal advice before making a claim as the policies and definitions can be complicated and there can be time limits for making a claim.
After assessing all the information provided, the insurer will make a determination to either accept, reject or defer the claim. If accepted, you will be contacted with options for payment. If deferred, the insurer is likely to undertake further assessments regarding the extent of your disability and whether the disability is permanent.
If you claim is rejected by the insurer, they have determined that your claim did not satisfy the conditions of the policy. There are a number of options available to you if the insurer denies your claim, which may include:
- A complaint direct to the insurance provider
- A complaint to the internal dispute resolution service of the insurer
- A complaint to the Financial Ombudsman
The information and wording used to support the complaint is very important and it is recommended that you contact your legal advisor regarding any denial of a TPD claim to obtain the best outcome.
Disclosure obligations imposed by TPD policies and exclusions
When applying for standalone TPD cover, you must disclose any relevant information to the insurer to allow them to appropriately assess the level of cover and cost of premiums.
If you fail to disclose any information later to be determined as relevant when you make a claim, the insurer may refuse to accept the claim. Further, if you fail to provide relevant information and the insurer is later informed of the failure, even in the absence of making a claim, the insurer may terminate the policy all together.
Disability caused by certain medical conditions can be excluded from TPD policies, particularly if you have suffered the condition in the past. Most commonly, exclusions for prior mental health conditions or complications resulting from underlying conditions such as diabetes, high blood pressure or other chronic diseases may result in a claim being denied.
Similarly, any disability or permanent condition caused by intentional self-harm will generally not be covered by TPD insurance.
If your job involves high risk work, the insurer may place certain exclusions on your policy, particularly if the injury or illness was caused by your employment. In addition, injuries arising from “dangerous” hobbies (i.e. Skydiving, drag racing, base jumping) may be excluded by the policy.
For tailored advice you should speak with your insurance broker to find out what insurance product is best suited to you.
If you need to make a claim, we recommend seeking early legal advice. For further information or discussion please contact a member of the Insurance team at HopgoodGanim Lawyers.