The most common form of insurance if you stop work due to injury or illness is a total and permanent disability (TPD) claim paid as a once-off lump sum benefit. The second and less common form is an income protection claim paid as a regular benefit (usually monthly) in place of your ordinary income. Whether you’re claiming a TPD lump sum benefit or income protection benefits, the need to be receiving medical treatment before, during or after your claim, differs.
You can learn more about the differences between these two types of injury/illness insurance in our blog, “What's the difference between income protection and TPD insurance?”
Are you unwell and considering stopping work and claiming TPD or income protection?
If you are unwell and considering stopping work due to ill health, it is expected that you would speak with your doctor about it.
Your ill health may have taken you by surprise, and you are now filling your days with specialist appointments and appointments with numerous allied health professionals.
Or, it may be the opposite. You may have been unwell for some time and are now managing your illness without medical care. You may not require any ongoing specialist or medical treatment because your condition is stable and will not change.
It is undoubtedly the case that regardless of whether you require ongoing medical treatment or you don’t because your condition has stabilised, it is preferred that you are seeking medical treatment before, during and after lodging a TPD claim or income protection claim.
Medical treatment when claiming TPD benefits?
A successful TPD claim is more likely if you have been receiving medical treatment
Of course, like everything in the law, there are shades of grey. It is, however, accurate to say that the process of lodging a TPD claim and the likelihood of being successful in the claim, significantly increases if you have been receiving medical treatment for the injury or illness related to your claim.
This does not mean that if you have not received medical treatment leading up to the date you stopped working, you are prevented from applying for and receiving a TPD benefit. Some circumstances reasonably explain why a person did not or was unable to, receive medical treatment before or after they stopped working. We discuss these circumstances below.
There are no specific rules regarding the level of medical treatment you must receive to lodge a TPD claim
There are no "hard and fast" rules in the insurance policy about the level or type of medical treatment you must receive to receive a TPD claim. This is a scenario that has many variables. It can depend on:
- the nature of your health condition;
- the accessibility of a relevant specialist;
- ongoing medication needs (that is, the need to return to your doctor to get further prescriptions);
- the need for your GP to monitor your health condition (if it is a condition that could worsen and should be monitored); and more.
The variables are many.
Successfully receiving a TPD benefit is about proving, with medical evidence (and other evidence), that you are totally and permanently disabled (as defined in the insurance policy) and are unlikely to return to work. Satisfying a TPD definition looks to the severity of your injury/illness rather than the number of times you have seen your doctor.
Specific medical evidence is required when lodging your TPD claim
The trustees and insurer will require you to provide medical evidence from a qualified medical practitioner (or GP) or medical specialist. The requirement to see a qualified medical practitioner (or specialist) will be deliberately worded this way in the insurance policy.
That does not mean you can’t provide other evidence from an allied health professional, such as a psychologist, chiropractor, osteopath, physiotherapist, counsellor, or others. But any evidence you provide from an allied health professional must be provided in addition to evidence you provide from a medical practitioner, not instead of evidence from a medical practitioner.
It goes without saying that evidence of your treatment from an allied health professional can bolster your claim. However, do not make the mistake of only lodging documents or reports from your allied health treaters and not from a medical practitioner because the claim will be rejected.
Medical treatment when claiming income protection benefits?
If you’re claiming ongoing income benefits on the grounds of stopping work due to a temporary disability, you have an obligation to remain under the care of your treating medical practitioner or specialist while receiving ongoing insurance benefits (usually called being “on claim”).
Receiving monthly income protection benefits is much different to the process described above regarding claiming a once-off lump sum benefit.
The assessment process for income protection benefits is usually ongoing. This usually requires the claimant to provide monthly (or quarterly if it can be arranged with the insurer) forms from their GP and also provide their own regular ongoing claim forms.
The insurance policy will usually state that a claimant must remain under the care of and follow the advice of a medical practitioner. For this reason, it is essential that you continue to see your doctor. And this means not just seeing your allied health professional on a regular basis, but also your doctor.
Potential implications for your TPD or income protection claim if you have not received medical treatment
There are circumstances where a claimant may not have been receiving treatment leading up to ceasing work or for many months afterwards.
This does not automatically preclude a TPD claim from being lodged or from being successful. But it does present challenges.
An insurance company is entitled to investigate the assertion that you stopped working at a particular time because of injury or illness. This can be difficult to prove if you were not under the treatment of a doctor when you stopped working.
This is a complicated area and one that is not easily condensed into an internet blog. If you’re having issues related to the medical evidence for your TPD or income protection claim, you should contact us for free advice.
Consider this scenario
Somebody stops working and then some months later is diagnosed with schizophrenia. Schizophrenia does not develop overnight, and one of the characteristics of the illness is to avoid medical treatment.
When that person then lodges a TPD claim, it becomes necessary to prove that the person’s condition was disabling at the time they stopped work, and it is their condition (schizophrenia) that was the reason they did not seek medical treatment at the relevant time.
This is not an impossible argument to win, but it is an argument that requires careful development.
Anytime medical evidence is difficult to obtain at or around the time a person stops working, an insurer will have no problems rejecting that TPD claim.
Get help from a TPD and income protection lawyer
If you’ve stopped work, whether permanently or temporarily, due to injury or illness, you should lodge a TPD claim for benefits. Although the claims process may look relatively straightforward, there can be many tricks and traps that TPD claimants face. If you’re unfamiliar with the process, this can lead to significant delays and rejected claims.
At Berrill & Watson, our team has extensive experience in winning TPD claims. We provide free advice, "no win no fee" and no upfront fees.
Contacting Berrill & Watson
📞 Melbourne: 03 9448 8048
📞 Brisbane: 07 3013 4300
📞 Anywhere else in Australia: 03 9448 8048
How we charge
We are Australia's best-value superannuation/insurance law firm. Other law firms charge nearly double (& sometimes more than double) what we charge. So, if you get a quote from them, or have a cost agreement, ask us what we will charge you.