Published 01 May 2018
Many TPD claims are declined for a very technical reason that the claimant was not “At Work”, alternatively called “Active Employment”, at the time of the disability. The insurer would then say the claimant is ineligible to claim under Unable to Work definitions and apply much harder Daily Activities definition. Most people would not satisfy these harder definitions.
This is particularly common in situations where people leave work for sickness, and not for personal injury - as there would only be treating notes from various doctors, and not any Expert Medical Reports prepared for say a personal injury claim. While this is very understandable as the sick person was not readying for a claim, the insurer relies on the “lack” of records to say the claimant became sick years later and was thus not “At Work”.
This happened to our client Mrs K from Bankstown. She had stopped work as a Retail Sales with Target some years ago due to back pain, she was unable to lift boxes or stock shelves due to the illness. At the time the doctors prescribed some pain medication and was unable to otherwise provide any relief. Our client tried various doctors but due to lack of help from them only attended them infrequently over time. It was later discovered, and diagnosed, that she had Chronic Pain Syndrome.
Sometime after the discovery of Chronic Pain, Mrs K submitted herself a TPD with her Super Fund, and the insurer for the fund denied the claim for the At Work reason. Namely that the Chronic Pain was years after the cessation of work. She hence sought advice from GMP. We took her case to court, before which we tendered further material to demonstrate the Chronic Pain was linked to the Back problems, but the insurer maintained their position.
As the matter was getting close to hearing the insurer engaged in negotiations with us to resolve this matter and they offered to pay $100,000.00 to settle the case – this representing a significant percentage of the insured sum. Our client accepted the offer and is greatly relieved with the outcome as the money received is directed to assisting her treatment.
A TPD case is often less straight forward then the Super Fund makes it out to be, especially because it is the insurer and not the fund which ultimately decides. It often is not just showing a person is sick and cannot work, but the date and timing of that is also critical. If the records are unclear the insurer could well rely on that grey to effectively not pay.
At GMP our lawyers have experience in conducting Insurance Claims, including TPD and Income Protection, and please don’t hesitate to contact us should you have a dispute or query for a free consultation.