For people who have ceased work due to a medical condition and are considering lodging a TPD claim or income protection claim, the TPD or income protection definition that applies to their claim could include very specific requirements in relation to their medical treatment. TPD and income protection definitions differ depending on who your insurance cover is with.
In this blog, we explore:
- medical treatment requirements;
- who medical treatment requirements affect;
- how medical treatment requirements might affect your TPD or income protection claim; and
- when it’s reasonable to refuse recommended medical treatment.
TPD and income protection definitions related to medical treatment
The TPD or income protection definition that applies to your policy may require that you have undergone all reasonable and usual treatment for your medical condition or that you are under continuous and ongoing care by a doctor.
The TPD or income protection definition that applies may even specify that you need to be treated by a general practitioner, specialist or both.
It is the case for every IP and TPD claim that you must undergo all medical treatment recommended by your doctors unless the recommended treatment presents an unacceptable risk for you. Some IP or TPD policy definitions also include express requirements relating to treatment, which may further complicate your claim or cause your claim to take longer. These requirements can even lead to a rejection of your TPD claim or a rejected income protection claim.
What are the medical treatment requirements for TPD and income protection claims?
In general, if you are claiming IP or TPD benefits, you must undergo all reasonably recommended medical treatment.
Usually, what is reasonable is that which is recommended by your doctor. If you seek to not undergo recommended medical treatment (ie, not have surgery, not take medication or engage in other treatments like Electroconvulsive Therapy (ECT)) your objection must be supported by your doctors.
However, for those that have TPD or income protection cover with requirements in their definitions that may relate to your medical treatment, the general requirements can be even more onerous.
An example of a particularly onerous TPD definition is the current Australian Retirement Trust/QSuper TPD definition, which contains the following medical treatment requirements:
- That you are treated by a general practitioner; and
- That you are treated by a specialist; and
- That there are no more reasonable treatment options left for you; and
- That even though you have undergone all reasonable treatment available to you, your medical condition is no longer likely to improve.
Another example is the AIA TPD definition, which contains the following medical treatment requirements:
- That you are treated by a general practitioner or specialist on an ongoing basis; and
- That there are no more reasonable or usual treatment options (including rehabilitation) left for you.
Who do TPD and income protection medical treatment requirements affect?
Medical treatment requirements for your TPD or income protection claim may affect you if:
- you have only recently stopped work because of an injury or a newly diagnosed medical condition; or
- you can’t afford to see a specialist, or haven’t been advised by your general practitioner to see a specialist; or
- you can’t afford medical treatment recommended to you (for example, an expensive surgery or rehabilitation program); or
- you have objections to the treatment options which are recommended by your doctors.
If any of the above apply to you, we recommend contacting us as we may be able to help.
How might an insurance policy medical treatment requirement affect my claim?
If you have recently stopped work because of a newly diagnosed medical condition, it may take months for you to undergo all reasonable treatment available to you. For example, it may take months to book in a recommended surgery or for your doctors to find the right medication to treat your medical condition.
This may delay the assessment of your TPD or income protection claim because the insurer may wait until you have undergone all reasonable medical treatment before deciding your claim.
If you have stopped work but haven’t been referred by your general practitioner to a specialist, this may also complicate or delay your claim, as the insurer may insist that you be seen or treated by a specialist before deciding your claim.
People who are pursuing a TPD claim and who don’t have income protection cover, and who aren’t eligible to receive any ongoing income from Centrelink are particularly disadvantaged by medical treatment requirements.
This is because they often can’t afford the medical treatment their doctors have recommended. Their TPD claims may be delayed while they are undergoing treatment or they may run out of money and have to stop or reduce their medical treatment.
For these people, the insurer may indefinitely delay deciding their TPD claim, or decline their TPD claim, until they have had further treatment (even if they can’t afford it!).
Even people with income protection cover may be affected by their inability to afford treatment if the insurer delays paying them their income protection entitlements because they may have limited leave entitlements or savings.
When is it reasonable to refuse available or recommended medical treatment?
During the assessment of your TPD or income protection claim, your doctors may recommend various treatment options to you that have a chance of improving the symptoms of your medical condition.
These recommended treatment options could include surgery, medication (e.g., anti-depressants), a rehabilitation program, a pain management program or other treatments such as Transcranial Magnetic Stimulation (TMS) or Electroconvulsive Therapy (ECT).
Although the treatment recommended to you by your doctor may have a chance of improving your symptoms, you may object to undergoing the treatment due to your concerns regarding risks of the treatment or regarding any potential side effects.
If you do not proceed with the treatment recommended to you by your doctors, the insurer may rely on this to decline your claim unless you can show you have reasonable reasons for not proceeding with the treatment.
Some examples of what may be considered a reasonable reason for not proceeding with medical treatment recommended by your doctor include:
- You are concerned regarding the side effects of the proposed treatment; or
- You are concerned regarding the risks of the treatment (e.g., risks associated with surgery); or
- You are unable to pay for the treatment, perhaps because it is not covered by Medicare or your private health insurance.
If any of the above apply to you, you may be able to refuse to undergo the treatment recommended by your doctor and still be paid your insurance benefits, but only if your refusal is reasonable, taking account of all of your circumstances. Risk factors which are unique to you are relevant, and your doctor(s) opinion about whether your refusal is reasonable is also a critical point.
Get help from a TPD and income protection lawyer
If you are struggling with any medical treatment requirements in your TPD or income protection claim or are ceasing work due to a newly diagnosed medical condition and want to understand how these requirements may affect your claim, we recommend you get in touch with us to discuss your claim. It costs you nothing to find out where you stand.
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