Jessica (a pseudonym) came to us in early 2022. She ceased work due to a shoulder injury in 2014. After ceasing work, Jessica suffered a hip injury that required surgery in 2018. She also suffered from another unrelated skin condition, which happened around 2020. Jessica lodged a TPD claim for her original shoulder injury, which was rejected. After many years and further injuries and illness, she sought legal advice and assistance, finally resulting in a successful TPD claim.
TPD claim rejected in 2016
Jessica lodged a TPD claim with her insurer, OnePath, related to her cessation from work due to her shoulder injury in 2014. This claim was rejected in 2016. At this time, the relevant TPD benefit was $500,000.
The TPD claim was rejected because:
- the doctors treating Jessica at this time (particularly her surgeons) did not think that her shoulder injury alone would cause her to cease work permanently; and
- the insurer had obtained a medicolegal report from an occupational doctor who had followed Jessica into the street after the appointment and said that her range of shoulder movement in the street was more than the range of movement observed when examining her. The doctor concluded that she must have been lying in the examination.
At the time the TPD claim was rejected, Jessica’s shoulder injury had not healed and had developed into a pain disorder, and her later hip injury also required surgery and continued to cause her ongoing, chronic pain.
Importance of the TPD definition
Prior to her shoulder injury, Jessica had worked in high-powered roles in the finance world, including as a financial controller and chief financial officer. However, immediately before ceasing work, she was working as a bookkeeper, and struggling.
The cover that Jessica had was “own occupation” TPD cover, which meant that to be successful with her claim, she needed to show that she had ceased work due to illness or injury and was permanently unlikely to return to work again in the occupation that she did in the 12 months before she ceased work.
Importantly, this was not TPD insurance cover that was held in her super. It was cover that she had bought with assistance from a financial planner. This meant that, unlike many other TPD benefits, which are held inside super, Jessica did not have to be working immediately before she became permanently unable to work due to injury or illness to satisfy the work-based TPD definition in her insurance policy.
You can read more about TPD definitions in our earlier blog, “Differences in TPD definitions effect how insurers pay out claims”.
The TPD definition in Jessica’s insurance policy was important because the condition that caused her to cease work in 2014 (her shoulder condition) had become much worse since 2014, and she then developed a hip injury in 2018.
If the relevant TPD definition was one that required her to be working immediately before ceasing work due to injury or illness, she may not have had a successful claim because the deterioration of the shoulder injury and the hip injury may not have been considered in the claim process.
Claimant seeks legal assistance from a TPD lawyer
Fortunately for Jessica, after meeting with her in 2022, we were able to reframe her case from when she had the hip operation in 2018, even though she wasn’t working at that time.
This was doubly important because she had waited more than 6 years from the time that:
- she ceased work in 2014 due to her injury; and
- her TPD claim was rejected in 2016,
to speak to a TPD lawyer.
Time limits to take further action related to the rejected TPD claim
Whilst it is true that there is no time limit for making claims under most TPD benefit definitions, Jessica’s policy was one that was worded in a way that meant that a time limit did apply. She most likely had to take court action within 6 years of ceasing work to meet the statute of limitations (time limit rules for legal proceedings).
In other words, because 6 years had passed since stopping work (and the original rejection of her TPD claim), we were not able to simply lodge a claim with a court about the decision to reject the claim.
Further medical evidence sought to support TPD
Due to the time limit issues, we went down the path of seeking medical evidence from Jessica’s treating doctors regarding the impact of her injury/illness from 2018. We also arranged for her to see a medicolegal orthopaedic surgeon to examine her and consider the extent of her injuries and ongoing work incapacity since 2018.
The medicolegal doctor provided a supportive report confirming that Jessica became TPD under the relevant definition in 2018 (at the time of her hip operation). We submitted this report to the insurer and asked that they assess a claim from 2018.
After some back and forth, the insurer accepted the TPD claim.
The kicker? In 2018, four years after the initial claim was made (related to the shoulder injury), the TPD benefit payable under Jessica’s policy had increased by around $200,000!
We are helping Jessica with an interest claim relating to the insurer’s delays in assessing the claim, and we hope to get her an award of interest in addition to her TPD benefit. You can read more about interest claims in our earlier blog, “When am I owed interest on my TPD or income protection benefit?”.
Get help from a TPD lawyer
Needless to say, this TPD payout has changed Jessica’s life and that of her daughter for the better. If you’re having difficulties with your TPD claim (unsure what disability insurance you have, rejected claim, delays by the insurer, etc), get in touch for some free advice. It costs you nothing to find out where you stand, and we run claims on a “no win, no fee” basis.
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