An essential requirement of claiming a TPD benefit is that you cease work due to illness or injury. The date that you ceased work due to illness or injury is sometimes also called your Date of Disablement. The Date of Disablement is not to be confused with the date that your employment is terminated (ie, when you quit or are fired).
Working out exactly when you last worked and from what date you should claim that you ceased work due to injury or illness, is a critically important factor in successfully claiming a TPD benefit, for the following reasons.
TPD insurance definitions can change
Under some insurance policies, if you change your work hours or duties, it can change the TPD definition which applies to your claim.
For example, under some insurance policies, if you are working fewer than 20 hours per week when you cease work due to illness, your TPD claim will not be assessed under a work-based TPD definition. Rather, it will be assessed under a more restrictive (and more difficult to satisfy) TPD definition - an Activities of Daily Living or loss of limbs TPD definition.
TPD insurance cover can stop
Your insurance cover may cease due to you not making premium payments or due to legislative requirements that mean that superannuation funds are forced to “switch off” insurance cover if the super fund is inactive for extended periods.
Therefore, it’s really important to make sure that the date from which you claim your TPD insurance benefit is a date that you actually have insurance cover. Your TPD benefit is assessed and payable from the date you stopped work due to injury or illness, not the date you lodge your claim.
TPD insurance benefits change over time
The amount of the benefit that you are entitled to if you stop working and are paid a TPD benefit, can either increase of decrease as you get older. So, getting the date that you last worked right, can sometimes mean a significantly larger benefit for you.
You will need your doctors’ support
You will be required to prove that you ceased work due to illness or injury and were permanently unable to work again from the time that you last worked or shortly thereafter.
Symptoms and illness/injuries change over time, as do doctors’ opinions. This means you must make your claim from a time that your doctors will support that you were unable to work due to illness or injury.
Further reading: “The importance of your doctors for a successful TPD claim”
You must satisfy the TPD waiting period
The TPD waiting period is the time that you must be off work and unable to work due to injury or illness before you can lodge a TPD claim under most TPD insurance policies.
The TPD waiting period is usually 3 or 6 months. If you work at all in the TPD waiting period, it will impact on your claim and your claim may even be rejected. This can be the case even if the return to work was for a short period or doing limited duties. For this reason, it is super important to claim your TPD benefit from a time that you were off work for an extended period.
Due to the above factors, giving thought to the date from which you claim that you stopped working due to injury or illness is very important. As you might imagine, many insurers will look to decide that you stopped working at a time that reduces the insurer’s liability or allows them to reject your claim.
The TPD insurer disputes the date you last stopped working
If the insurer decides that you last worked on a date that adversely impacts on your claim, you may be able to take the following actions.
Check your doctors’ statements
Often the insurer will rely on the doctors’ statements submitted with the claim forms to work out when you last worked. If the doctors have said that they are unsure or uncertain or they have stated that you last worked on a date which is different from the date that you actually ceased working, this can cause issues.
It’s important that this is carefully checked before the TPD claim is lodged. If doctors’ statements submitted with the claim are not entirely supportive or they are asked to later write a report about your condition and it is not entirely supportive, we recommend getting updated statements from your doctors clarifying the earlier statements and submitting them to the insurer.
Check your Employer Statement
Another reason that your insurer may dispute when you stopped working is because your employer has completed the Employer’s Statement and provided a different date to that from which you are claiming. This can happen if your work has been on and off toward the end or when your employer confused the date that you last worked with the date of your termination of employment.
If this happens, you should consider:
- getting an updated Employer’s Statement completed;
- gathering payslips or tax documents to support when you last worked; and/or
- getting statements from co-workers regarding your work and limitations.
In most cases, returns to work are OK if they occur outside of the TPD waiting period and are limited in time and you are completing limited duties.
Provide statements to the insurer
A sworn statement from yourself, along with the documents which we have referred to above, can also help. Giving additional details about when you stopped work and any return to work which you may have undertaken can assist by giving context.
However, we do not recommend that you do this without first getting advice.
Check your TPD policy
Some insurance policies are prescriptive about when you are considered to have stopped work due to illness or injury for the purposes of a TPD (or income protection) claim.
It’s important to understand these requirements as much as you can before you make a claim, as understanding the requirements and framing the case for success can be the difference between an accepted or rejected claim. This is particularly important if your cessation from work was complicated by failed attempts to return to work prior to ceasing all work.
Even after a claim is lodged and any benefit reduced or limited due to the insurer disputing when you last worked, it’s important that the terms in the policy which are relevant to the definition of TPD and elsewhere, are understood and properly interpreted.
This is because it may be possible to reframe the case with help from employers, and/or medical professionals, to change the date that you claim to have last worked. Also, there are clauses in the Insurance Contracts Act 1984 which can prevent the insurer from relying on broad pre-existing exclusion clauses or other clauses which are unfair and can be relied on to challenge the insurer’s decision.
Get help from a TPD lawyer
We are super insurance experts. If you’re having any issues with your TPD claim (delays by the insurer, rejected claims or any other issue) or you’d like help lodging your claim, contact a member of our team. We offer free advice, ‘no win no fee’ claims, and no upfront fees.
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