TPD claims resources, page 14

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Featured guides

The four guides on this page sit together because insurers often test physical injury claims by looking beyond the injury label. They may ask what treatment has been tried, whether restrictions are permanent enough, whether there was a relevant history before cover started, whether an independent examiner agrees with the treating doctors, and whether delay is caused by missing evidence or a genuine dispute.

What this page helps you answer

Use this page when your TPD claim question is practical rather than abstract. It helps you decide which record should answer each issue: the treating doctor's report, the IME report, the employer duty statement, the pre-cover medical chronology, the rehabilitation record, or the insurer's outstanding request.

• If the injury is accepted but work capacity is disputed, focus on duties, restrictions, treatment response, medication effects, and whether lighter work is realistic rather than simply naming the diagnosis.
• If an IME is coming up, prepare a clear history of duties, symptoms, treatment, good days and bad days, failed work attempts, and documents the examiner should have, without exaggerating or rehearsing a legal conclusion.
• If a pre-existing condition is raised, separate background symptoms from the later point at which reliable work became unsustainable, and check the actual policy wording before assuming the issue defeats or does not affect the claim.
• If the claim is delayed, map each outstanding request to a policy question so the next response is targeted rather than another unsorted document bundle.

How to use these guides together

Start with the physical injury guide if the claim is based on a back injury, shoulder injury, joint damage, chronic pain after trauma, neurological symptoms after an accident, or another physical condition that affects ordinary work. A useful TPD file usually explains the actual duties of the job, the physical demands of those duties, the treatment already tried, the current restrictions, and why those restrictions are likely to prevent suitable work over the long term.

Then read the independent medical exam guide if the insurer, trustee, or fund has asked you to attend an assessment. An IME is not just a routine appointment. It can become a key piece of evidence about diagnosis, functional capacity, treatment options, consistency, and whether the assessor thinks some type of work remains realistic. Before attending, check the appointment scope, bring a clear symptom and treatment history, avoid exaggeration, and make sure your treating doctor evidence already explains the work impact in practical terms.

The pre-existing conditions guide is important where symptoms, investigations, or treatment existed before the policy started, before an increase in cover, or before a change in employment. A prior condition does not always defeat a TPD claim. The real questions are usually whether the exclusion or underwriting wording applies, what was known at the relevant time, whether the later incapacity is caused by the same condition, and whether the claim can be supported by careful medical chronology rather than assumptions.

Evidence and delay controls for this part of the archive

For physical injury claims, evidence is strongest when it links medical findings to work reliability. A scan result or diagnosis may help, but the insurer normally needs to understand lifting limits, sitting or standing tolerance, medication effects, flare patterns, treatment response, future surgery expectations, concentration impact, and whether retraining or lighter duties are realistic in the claimant's circumstances.

Delay often happens when documents answer different questions. A surgeon may describe impairment, a GP may describe symptoms, an employer may describe duties, and an insurer may ask about any occupation or own occupation capacity. If those materials are not connected, the reviewer may ask repeated follow-up questions. A short index that maps each policy issue to the relevant report, employment record, treatment note, or timeline entry can make the file easier to assess.

If the insurer says the evidence is inconsistent, do not respond by sending a larger unsorted bundle. Identify the exact inconsistency first. It may involve dates, restrictions, pre-injury duties, post-injury attempts, surveillance comments, rehabilitation notes, or language in a workers compensation or income protection file. The useful response is usually a structured explanation supported by documents, not a general statement that the claimant is unfit for work.

Where a physical condition has developed over time, keep the chronology clear. Separate the date cover started, the date symptoms first affected work, the dates of major investigations, the dates treatment changed, the last day of ordinary work, any attempted return, and the current medical opinion about permanence. This helps avoid a reviewer wrongly treating an old diagnosis as proof that the current incapacity was always present, or treating a short work attempt as proof that normal work capacity has returned.

Preparing for an IME without weakening the claim file

An independent medical examination can be useful, neutral, or contested depending on how the report deals with the real policy questions. Before the appointment, it is usually sensible to review your job duties, treatment history, medication list, functional restrictions, failed rehabilitation attempts, and the difference between a good day and sustainable paid work. The point is not to rehearse answers. The point is to avoid leaving out facts that explain why apparently simple activities may not translate into reliable work.

After the appointment, write a brief record while the details are fresh. Note the time spent, the body parts or symptoms assessed, any functional tests, any history taken, and whether important documents appeared to be missing. If the later report contains assumptions that do not match the records, those notes may help your adviser or treating doctor respond in a focused way. Do not assume every unfavourable IME comment is fatal, but do not ignore a report that misstates duties, treatment, symptom frequency, or work capacity.

When pre-existing condition questions need careful handling

Pre-existing condition issues need careful reading of the policy and the evidence. The relevant question may be whether a condition was excluded, whether it was disclosed, whether underwriting applied, whether cover was automatic or voluntary, or whether the current incapacity is caused by the same medical problem. A fair claim response usually needs dates, medical records, application documents, and a causation explanation rather than a broad denial that anything existed before cover.

It can also be important to distinguish background symptoms from disabling incapacity. For example, a person may have had intermittent pain or investigations before cover started, but may only have become unable to continue suitable work after a later deterioration, injury, surgery, treatment failure, or cumulative functional decline. The evidence should explain that pathway accurately. Overstating the history can create unnecessary exclusion risk, but understating it can damage credibility if the insurer later obtains earlier records.

Helpful next links from page 14

If you are still assembling the claim, read evidence required for a TPD claim, what evidence is needed for a TPD claim, and the TPD claim readiness checklist. If the file involves a failed return to work, compare the injury evidence with TPD after a failed return-to-work attempt, short return to work with reduced duties, and employer modified duties followed by relapse. If the insurer is focusing on definitions, read any occupation versus own occupation TPD definitions before answering.

If the physical injury also overlaps with another system, compare the TPD evidence with TPD and workers compensation, CTP or workers compensation and TPD claims, and TPD and income protection. Those systems can use different tests, so consistency matters, but one file should not be copied into another without checking the question being answered.

Page 14 resources FAQ

Does a physical injury diagnosis automatically prove TPD?

No. A diagnosis is only part of the file. The claim usually needs evidence showing how the condition affects reliable work capacity under the relevant policy definition.

Should I attend an independent medical examination requested by the insurer?

Do not ignore the request. Check what is being asked, prepare an accurate history, and seek advice if the request appears unreasonable, unclear, duplicated, or inconsistent with your policy or medical circumstances.

Can a pre-existing condition stop a TPD claim?

Sometimes, but not always. The answer depends on policy wording, underwriting history, timing, medical causation, and what was disclosed or known at the relevant time.

What should I do if the insurer says my physical injury evidence is inconsistent?

Ask what inconsistency is being relied on, then respond to that point with dates, duties, medical reports, treatment notes, and any return-to-work records. A targeted explanation is usually more useful than a larger unsorted bundle.

Can a short return to work defeat a physical injury TPD claim?

Not automatically. The relevance of a work attempt depends on the duties, hours, support, symptoms, reliability, why the attempt ended, and how the policy defines TPD. The records should explain whether the attempt showed sustainable capacity or only a limited trial.

What is the safest first step if several issues apply at once?

Build a dated chronology before sending more material. List the cover dates, injury or symptom history, work changes, treatment milestones, IME appointments, insurer requests, and failed work attempts, then match each item to the policy issue it supports.