Total & Permanent Disability

Guide to TPD Claims for Mental Illness

By LHD Lawyers

There are countless different types of insurance policies, each with their own definitions, requirements and definition. These policies also vary year to year. This can make it very difficult to understand your entitlements or even if you are covered at a particular date.

When added to poor mental health, this can make the process of claiming nearly impossible.

Can I make a claim for mental illness?

Generally, yes, you can make a claim for mental health issues.

If you hold Total and Permanent Disablement (TPD) or Income Protection (IP) cover, and have ceased work as a result of this, you might be eligible to make a claim.

It is a common assumption that only physical injuries are covered, or that mental health issues are excluded from insurance policies.

While there are some exceptions (such as specific policy exclusions), a mental health condition is treated the same as a physical condition.

Similarly, insurers offering Life Insurance policies are no longer allowed to offer policies which have an automatic exclusion for mental health conditions.

What if my mental health condition was not related to a workplace accident?

Another common assumption is that you can only claim a mental health condition if it is a new injury, or one caused by a workplace/ motor vehicle incident.

This is not correct.

Depending on the policy, claims can be made for pre-existing conditions if they have deteriorated, or for mental health issues arising from genetic or other circumstances. This means that conditions such as bi-polar, schizophrenia or long-term chronic depression can all be considered.

What if I have multiple conditions?

Poor mental health is common in people who have suffered physical injuries. Unlike with other types of personal injury claims, mental health can also be considered when determining if you are eligible for TPD or IP benefits.

What if my mental health issues arose after I ceased work?

With the majority of policies there is a threshold requirement that you have ceased work as a result of illness or injury. Following this, medical evidence must show that the injury or illness renders you unlikely to return to work within your education, training or experience.

This can become complicated in cases where a person has suffered an initial injury which stopped them from working and then developed poor mental health as a result of the injury. in cases where the physical injury resolves and the mental injury remains, the question becomes am I eligible to claim.

The answer is that it is definitely possible. The individual facts of the matter and the timeline are important in these cases. As long as the poor mental health can be referenced to the initial injury and the definition is satisfied, a claim should be successful.

What if my mental health gets worse after I cease work?

The previous approach to mental health claims were that if, at the time you ceased work, the medical opinions were unclear, the condition not fully diagnosed or the symptoms not as manifest, a claim would be declined.

Thankfully for people suffering poor mental health, this is no longer the case. There have been a number of court decisions which look at mental health more holistically.

It is now understood that mental health conditions are not linear. Sufferers experience fluctuations in the severity of the condition and it can take some time for the mental condition to reach a stable point.

The court now looks at the progression of mental health illness in the months and sometimes years after someone stops working. If a clear progression can be drawn then the time they ceased work to the current date through treatment, medication and time to determine if an individual meets the insurance requirements.

What are pre-existing conditions?

A pre-existing condition is one that was reasonably known prior to the commencement of the policy. Generally retail policies will exclude these conditions. Some group policies also have exclusions for pre-existing conditions for a period of time.

This is not always straight forward. There are instances where claims can be successful despite a pre-existing condition.

For example, you might have an old lower spine injury and, as a result of that, the fund excludes any claims relating to the back. If you suffer a new, frank injury to your upper spine that renders you TPD it might be possible to make a claim depending on the policy wording.

It is always advisable to seek a legal opinion as the policies can be complex.

How does a TPD claim for mental illness work?

Ideally TPD claims for mental illness start before you even suffer TPD mental illness, by ensuring that you have cover with your superannuation fund for TPD mental illness. You can look at your policy when you take it out and ensure that you are able to claim TPD for mental illness. You can also take out other options with your policy like claiming TPD for mental illness if you are unable to work in any occupation or just your particular field of expertise. You can also ensure you are covered for assistance in running your home should you need to make a TPD claim for mental illness and are no longer able to run the household.

If you have suffered a TPD mental health injury, the process for claiming TPD for mental illness involves meeting the required disability level, satisfying minimum wait times and fulfilling all the requirements around work history. If you are suffering a TPD mental health injury, making a claim can be daunting, which is why it is a good idea to employ expert TPD mental health lawyers to support you throughout the process.

What are the requirements for mental health claims?

The requirements for mental health claims vary fund to fund and policy to policy.

At a basic minimum, you will need medical evidence to show that you were suffering from a mental health condition at the time you ceased work. This can be through complaints made to a GP.

When suffering a mental health issue, it is important to follow the advice of your treating doctor such as attending psychology or psychiatry sessions.

Insurance claims are primarily medically based. This means that seeking medical treatment is an important component of the claim.

What TPD mental health injuries can be claimed?

A TPD claim for mental illness involves a mental illness which has been diagnosed by a doctor, in order to be considered a TPD mental health injury, this mental health disorder needs to interfere with your social, emotional or cognitive abilities so much so that you are permanently disabled. Conditions which may be considered when claiming TPD for mental illness include:

Severe anxiety: this TPD mental illness can include breathing difficulties, panic attacks, racing heart and a fear of open spaces
Severe depression: this TPD mental illness can include being unable to do simple tasks such as getting dressed or leaving the house, rendering you unable to function
Post Traumatic Stress Disorder: this TPD mental illness can include panic attacks, anxiety and depression symptoms due to experiencing a traumatic event

You may be denied TPD payment due to your mental state being declared legally competent. So it’s important to regularly see a healthcare professional and keep good records in order to increase your TPD claim mental illness success rate.

How long can a TPD claim for mental illness take?

TPD claims for mental illness can unfortunately take a long time to process. You can be denied TPD payment due to mental state legally competent, so you need to ensure you have regular treatment from a doctor or psychiatrist/psychologist and ensure you are well engaged with them – this is the key to a higher TPD claim mental illness success rate. A simple TPD claim for mental illness can take two to three months however, more complex cases can take from six months to multiple years to settle.

What if my claim is declined?

If your claim has been declined, get legal advice straight away. Once a decision has been made on a claim, you only have a limited amount of time to challenge it and the quicker you do so, the better.

The timeframe for taking a matter to court is generally 6 years from the date of the decision. If you do not commence court proceedings in this time then you may be statute barred from doing so.

Why choose LHD lawyers for a TPD claim for mental illness?

Insurance claims can be complex and emotionally taxing in general. When also suffering poor mental health, they can seem impossible.

We have a team of experts who can assist you through this process so that you can focus on treatment and recovery. This is why it is advisable to have expert TPD mental health lawyers in your corner when claiming TPD payouts for mental illness.

Author: Lisa Meys

Original Publish Date: October 5, 2020

Last Updated: May 23, 2024