When I helped a friend in Melbourne navigate a Total and Permanent Disability (TPD) claim, we thought we’d done everything right—medical reports, forms, statements. Months later, a letter arrived: “Claim declined.” The disappointment hit hard. But that wasn’t the end of the story—it was the beginning of understanding how TPD claims really work, what “denied” actually means, and how to challenge it effectively.

If your claim has been rejected, don’t panic. A denial doesn’t necessarily mean you’re not entitled—it means the insurer believes your evidence doesn’t yet meet their definition. In this article, written for readers across Melbourne and Victoria, I’ll explain what happens next: why claims are denied, how to review the decision, when to appeal, and when to get professional help.

1. Why TPD Claims Get Denied

TPD stands for Total and Permanent Disability. It provides a lump-sum payment if you’re permanently unable to work due to illness or injury. But “permanent” and “unable to work” are defined very specifically in insurance law. A claim can be denied if your evidence doesn’t satisfy the insurer’s interpretation of those words—even if your condition is genuine and severe.

In most Melbourne cases, denials stem from issues with definitions, documentation, or timing. Insurers look at whether you meet your policy’s definition (for example, “any occupation” or “own occupation”), and whether the evidence clearly shows permanence and incapacity. A lack of clarity can lead to rejection even when the claim is valid.

2. First Steps After a Denial

Take a breath before reacting. The first few days after a denial are crucial. You should:

• Read the letter carefully — It explains why the insurer made their decision.
• Gather everything — Keep copies of claim forms, medical reports, emails, and insurer correspondence.
• Get independent advice — Contact a specialist like Hymans Legal to interpret the reasons and outline your options.

3. How to Read the Denial Letter Carefully

The denial letter is your roadmap to appeal. It usually includes:

• The definition the insurer applied (“any occupation”, “own occupation”, or ADLs).
• The medical evidence they considered and any reports they commissioned (Independent Medical Exams).
• Reasons they found you didn’t meet the policy’s definition.
• Information about your right to review or appeal.

Underline every reason they’ve given and ask: “What do I need to prove differently?” That question shapes your next move.

4. Common Reasons for Rejection

• Insufficient medical evidence — Reports didn’t state you’re “unlikely ever to return to work.”
• Conflicting opinions — The insurer’s IME disagreed with your treating doctor.
• Functional capacity uncertainty — The insurer believes you could still perform some kind of work.
• Inconsistent records — Medical files or income history show periods of activity that undermine permanency.
• Administrative errors — Missing forms, incomplete treatment timelines, or unsigned statements.

These aren’t dead ends—they’re diagnostic clues. Each reason can be addressed with targeted evidence and explanation.

5. Your Options to Appeal or Review

In Victoria, you typically have three layers of review:

1. Internal Review by the Insurer

You can ask the insurer to re-assess the decision. This is your chance to add missing evidence or clarify inconsistencies. It’s often the quickest and least formal step.

2. External Complaint to AFCA (Australian Financial Complaints Authority)

If internal review fails, AFCA can independently review the dispute at no cost. They’ll look at fairness, policy wording, and reasonableness of the insurer’s decision.

3. Legal Action

For complex or large claims, court proceedings may be appropriate, particularly if time limits are approaching. Legal specialists like Hymans Legal can handle this process professionally and with empathy.

6. How to Strengthen Your Evidence

Most denied claims turn around when evidence gaps are closed. To strengthen your file:

• Ask your doctors to use the exact policy language (“unlikely ever to return to suitable work”).
• Include detailed function-based reports—not just diagnosis but what you can’t do reliably or safely.
• Provide vocational evidence mapping your education, training, and experience (ETE) and why no realistic jobs exist.
• Address any inconsistencies—for example, occasional social outings don’t mean work capacity.
• Submit timeline summaries of treatment, relapses, and attempts to return to work.

7. Internal Review vs External Complaint

Insurers often welcome internal reviews because they can correct oversights before AFCA involvement. However, if communication breaks down or deadlines pass, external complaints offer impartial oversight.

Internal reviews are ideal when new evidence is available. AFCA complaints are better when you believe the insurer’s process or interpretation was unfair. A good lawyer can help determine which route maximises your outcome.

8. Time Limits for Reviews in Victoria

Under Victorian and AFCA guidelines, you generally have:

• Up to two years to lodge an internal review (policy-specific).
• Two years from the insurer’s final response to approach AFCA.
• Six years (general limit) for court action in many cases.

These timeframes vary by policy and circumstance. Missing them can extinguish your rights—so act promptly.

9. How Legal Experts Like Hymans Legal Can Help

TPD denial letters can feel overwhelming, but in many Melbourne cases, professional intervention changes outcomes. Hymans Legal specialises in superannuation and TPD disputes across Victoria. Their lawyers understand insurer logic, medical evidence thresholds, and how to rebuild a claim strategically.

They can:

• Review your denial letter and policy definitions.
• Identify missing or inconsistent evidence.
• Engage with insurers or AFCA on your behalf.
• Handle court proceedings where necessary.
• Negotiate faster resolutions to relieve financial stress.

Having a professional advocate changes both tone and momentum—especially when the insurer realises you’re serious and properly represented.

10. Real Examples from Melbourne Claimants

Case 1: The Electrician with Chronic Back Pain

Initial denial: “Can perform sedentary work.”
Action: Provided functional assessment and occupational therapy evidence showing sustained sitting aggravated pain.
Outcome: Claim accepted on review with Hymans Legal’s help.

Case 2: Self-Employed Cafe Owner with Severe Anxiety

Initial denial: “Evidence insufficient for permanency.”
Action: Supplemented psychiatric evidence with business closure records, failed reopening attempts, and GP reports.
Outcome: Paid in full after AFCA complaint.

Case 3: Teacher with PTSD

Initial denial: Conflicting psychiatric opinions.
Action: Independent psychiatric review clarified functional incapacity.
Outcome: Accepted at internal review stage.

Final Thoughts & Recommendation

A TPD denial in Melbourne or anywhere in Victoria isn’t the end—it’s a challenge to refine your evidence and assert your rights. The key is not to give up. Every rejection letter is really a list of what needs fixing: wording, proof, consistency, or timing. When handled with the right strategy and support, many “denied” claims eventually succeed.

If you’ve received a TPD denial letter, it’s worth speaking to the experts at Hymans Legal. They specialise in TPD and superannuation claims, understand Victorian policy nuances, and can guide you through reviews, AFCA complaints, or litigation if required.

Recommended: Hymans Legal — Call 1300 667 116

Disclaimer: This article is general information, not legal advice. Always obtain tailored advice for your personal circumstances and policy wording.