How a TPD claim works, and where psychological reports fit

Most super funds automatically include total and permanent disability (TPD) insurance for members aged 25 and over who have at least $6,000 in their account. If an illness or injury means you cannot work again, a TPD claim may pay a lump sum.

When the illness is a brain injury or a mental health condition, a psychological or neuropsychological report can help explain how it affects your ability to work. Below, each step of a claim is mapped out, with where reports fit and your rights along the way.

The TPD claim path at a glance

Every claim is different. Even so, this is the usual path for a TPD claim through super.

1. 1

   Stopping work

   After an illness or injury

   What happens

   A brain injury, mental health condition or other illness means you cannot keep working, or may never return to your usual job.

   What you can do

   Look at your super statement or call your fund to check whether you have TPD cover and which definition applies.

2. 2

   Getting advice

   Early

   What happens

   TPD claims can be complex. For this reason, many people get help from a lawyer, a community legal centre or a financial counsellor.

   What you can do

   Call the National Debt Helpline on 1800 007 007 for free financial counselling. Also ask about time limits early.

3. 3

   Lodging the claim

   Through your super fund

   What happens

   Your fund gives you claim forms. The insurer usually asks for reports from your treating doctors and information from your employer.

   What you can do

   Keep copies of everything you send. Then ask the insurer what evidence it needs.

4. 4

   Medical and psychological evidence

   While the claim is assessed

   What happens

   The insurer may ask your doctors for reports, or arrange an independent medical examination and pay for it. Your lawyer may also arrange an independent psychological or neuropsychological report.

   What you can do

   You can ask the insurer for a list of practitioners to choose from, and for a copy of the report.

5. 5

   The assessment

   Several hours, with breaks

   What happens

   We read the referral questions and your records. Then we interview you about your health, work and daily life, and you complete tasks on memory, attention and thinking. Validity checks are also routine for everyone.

   What you can do

   Bring glasses, hearing aids and a list of medicines. Also tell us about pain, fatigue or the need for an interpreter.

6. 6

   The report

   Usually 2 to 3 weeks later

   What happens

   The report answers the questions asked: your thinking skills and mental health, the likely causes, treatment needs, outlook, and what this means for work.

   What you can do

   The report goes to whoever asked for it, such as your lawyer or the insurer.

7. 7

   The decision

   The Code says within 6 months

   What happens

   The insurer decides the claim. The Life Insurance Code says lump sum claims should be decided within 6 months of the claim being received.

   What you can do

   If the claim is declined, complain to your fund first. If you are still unhappy, AFCA offers free dispute resolution.

What TPD insurance is

Moneysmart, the government’s money guidance website, explains that TPD insurance pays a lump sum if an illness or injury leaves you permanently unable to work. It is also often held inside your super. Moneysmart’s page on insurance through super adds that most funds give it automatically if you are 25 or over and have at least $6,000 in super. In that case, premiums come out of your super balance.

However, each policy has its own definition of disability. Two common types are:

Moneysmart notes that own occupation cover costs more and is usually only available outside super. The insurer applies the wording in your policy, which is why the questions in a report matter so much.

Where a psychological or neuropsychological report fits in a TPD claim

Insurers make TPD decisions based on medical evidence. However, a psychologist or neuropsychologist does not decide whether you meet the policy definition. Instead, their job is to give a fair, independent opinion that helps the insurer, and anyone reviewing the decision, understand your situation.

A report may describe:

• your thinking skills, such as memory, attention, speed of thinking and problem solving
• your mental health and how it affects daily life
• what is likely causing your difficulties, such as a brain injury, pain, medication or mood
• treatment you have had, and what else might help
• your likely outlook
• what your results mean for the demands of work, including jobs suited to your education, training and experience

A report is most useful when the questions are clear. If a lawyer refers you, they will usually set out the questions the report should answer.

Your rights during a TPD claim

Life insurers that subscribe to the Life Insurance Code of Practice make commitments to claimants. They include:

• If the insurer arranges an independent medical examination, it pays for the appointment and the report.
• You can also ask for a list of practitioners to choose from.
• Where possible, the insurer avoids asking for more than one examination by the same type of practitioner within 6 months.
• Lump sum claims should be decided within 6 months of the claim being received.
• For people with a mental health condition, insurers commit to treat you with empathy, compassion and respect, to not discourage you from claiming, and to work with you if you have trouble providing information.

The Code binds insurers. It does not automatically bind super fund trustees, unless they have adopted it.

If your TPD claim is declined

ASIC says to complain to your super fund trustee first. If you are not happy with the response, the Australian Financial Complaints Authority (AFCA) offers free, independent dispute resolution on 1800 931 678. Strict time limits apply to TPD complaints, so check with AFCA or a lawyer as soon as you can.

How Invictus Health can help

Our psychologists and neuropsychologists provide medico-legal assessments, including reports for TPD claims through super and other insurance claims. We answer the questions asked, with our reasons. Neuropsychology reports are also reviewed by Dr Judy Tang OAM.

Fees for medico-legal reports start from $3,300 including GST, and may be higher for complex cases. Depending on the claim, the fee may be paid by you, your lawyer or an insurer. However, Medicare does not cover medico-legal assessments. For lawyers and other referrers, our referral guide explains how to send a referral and documents securely.

If cost is a barrier, please talk to us. We have these conversations all the time, and it’s OK to ask.