TPD Claim Rejected? Your Options and How to Appeal

The first 30 days after rejection

1. Don't sign anything in the heat of the moment. Some insurers will offer a small "settlement" or release of cover that ends your right to appeal. Read every document before signing.
2. Get a copy of the entire claim file. You're entitled under privacy law to all medical reports, surveillance, file notes, and the assessment matrix. Request it in writing.
3. Read the rejection letter carefully for the exact reason given. Insurers must specify which part of the policy definition you failed to meet.
4. Get a free claim review. Specialist TPD lawyers will assess your file at no cost and tell you whether the rejection is defensible. Most appeals are taken on no-win-no-fee.
5. Note the deadline. Internal dispute resolution sets a 45-day clock; AFCA sets a 6-year clock from the original decision but practical strategy demands quick action.

Common rejection reasons (and which are defensible)

"You don't meet the TPD definition"

The most common reason. Often defensible — particularly when the insurer's interpretation of "Any Occupation" relies on theoretical rather than realistically available work. AFCA repeatedly finds that suitability must consider real-world labour market access in the claimant's region and circumstances.

"Insufficient medical evidence"

Defensible by getting better-targeted reports. Existing treating specialists can provide supplementary letters specifically addressing the policy definition (rather than clinical findings).

"Pre-existing condition exclusion"

Defensible if you can show that your condition meaningfully changed in nature or severity after the cover started. The PDS wording controls — and the burden of proof is on the insurer to establish the exclusion applies.

"Non-disclosure on application"

Harder to defend, but not impossible. Insurers must show that any non-disclosure was material and that they would have declined cover or imposed terms had they known. Innocent omissions in default cover (where you didn't actively complete an application) often don't satisfy this test.

"Date of disablement falls outside cover period"

Defensible with payroll records, employer letters, and treating-doctor records establishing the actual date you stopped work.

Internal dispute resolution (IDR)

Before AFCA, you must first complain to the super fund and give them 45 days to respond. The IDR letter should:

• Set out the specific aspect of the decision you dispute
• Identify any errors in the insurer's analysis (e.g. misreading a medical report)
• Attach any new or supplementary evidence (treating-doctor letter, employer statement)
• Address the trustee's separate duty to consider your best interests under the SIS Act, not just rubber-stamp the insurer

Around 20% of TPD claims are reversed at IDR without needing AFCA, particularly where new evidence is presented or where the trustee independently identifies an error.

The AFCA process

If IDR doesn't resolve the dispute, you can lodge with AFCA at afca.org.au — free and binding on insurers up to $1,201,000.

AFCA stages:

1. Lodgement — submit complaint, get case reference
2. Case management — case officer assigned, scope clarified
3. Negotiation / conciliation — most claims resolve here, typically months 2 to 6
4. Preliminary assessment — AFCA's tentative view, parties given time to respond
5. Final determination — binding on insurer up to AFCA jurisdictional cap

AFCA decisions are searchable at AFCA's online decision database. Reading determinations on similar conditions/funds is genuinely useful for understanding how AFCA reasons.

New evidence on appeal

On internal review and at AFCA you can introduce new evidence, but it must be probative and relevant. Effective new evidence usually includes:

• Updated specialist report addressing the gap the insurer identified
• Vocational assessment from an occupational therapist showing realistic labour market access
• Functional capacity assessment
• Statements from former employers confirming work restrictions and modified duties
• Day-in-the-life evidence (where relevant) showing functional limitations not captured in clinical notes

Appeal success rates

Combining AFCA published data and law-firm reporting, the rough figures are:

• ~20% of rejections reversed at IDR
• ~30 – 45% of AFCA-lodged rejections resolved in claimant's favour (determination + change of position)
• Combined: roughly half of properly-prosecuted rejections are eventually paid

That doesn't mean every rejection is overturnable — some are correctly decided. But it does mean a rejection should be reviewed by a specialist before you accept it.