Written by: Angelica Adhar If your total and permanent disability (TPD) claim has been rejected or declined, you still have options. A rejection is the insurer’s view of your claim at first decision, not a final outcome. Many rejected or disputed TPD claims are overturned through internal review, AFCA, or with the help of a TPD lawyer.
In this May 2026 guide, we explain why TPD claims are rejected, what to do if your claim has stalled instead of being formally declined, the options available to challenge a rejection, the time limits that apply, and when to speak to a lawyer.
Why was my TPD claim rejected?
Insurers reject TPD claims when they believe the evidence does not meet the policy definition. That decision generally comes down to medical evidence the insurer considers insufficient, or a disagreement about which definition of TPD applies to your claim.
The most common reason TPD claims are rejected is the insurer arguing that your condition does not meet the policy definition.
What is my insurer’s policy definition?
Two of the most common policy definitions are own occupation and any occupation. Under an own occupation definition, you need to show you cannot return to the specific job you were doing when your condition began. Under any occupation definition, you need to show you cannot return to any role suited to your education, training, or experience.
For example, a builder whose treating doctors confirm they cannot return to physical work may still have their claim declined under an “any occupation” definition if the insurer believes they could perform a supervisory or estimating role, even where they have no experience in those areas.
Common reasons TPD claims are rejected
Other common reasons TPD claims are rejected or declined include:
- Insufficient or inconsistent medical evidence
- The insurer argues your condition does not meet the policy definition (own occupation vs any occupation)
- Disputes over the date of disablement, particularly for conditions that developed gradually
- Your cover was inactive or had lapsed at the time of disablement
- Pre-existing condition exclusions
- Non-disclosure of medical history when the policy was taken out, which can lead the insurer to cancel your cover
- An attempted return to work is treated as evidence of work capacity
- Mental health conditions assessed under stricter evidentiary standards.
“Rejected” and “declined” are the same thing. A rejection letter is the insurer’s decision at first assessment, not a final outcome, and you can challenge it.
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What are your options if your TPD claim is rejected?
If your TPD claim has been rejected or disputed, you have four options to challenge the decision: request the insurer’s written reasons, lodge a complaint through internal dispute resolution, escalate to AFCA, or commence court proceedings. Most rejected TPD claims resolve through one of the first three.
Each option is generally taken in order, with internal review usually completed before AFCA accepts a complaint, and AFCA usually considers the matter before court proceedings are appropriate.
Here’s what to do if your TPD claim has been rejected:
1. Request the insurer's written reasons letter
If the insurer has not provided a detailed reasons letter, you can request one in writing. The reasons letter sets out the specific basis for the rejection and is the starting point for any review.
When you request the letter, also ask for a copy of the full policy document, not just the extracts the insurer relied on in their decision. The wording around your specific claim can differ from the headline definition, and the full policy is what governs your entitlements.
2. Lodge a complaint through internal dispute resolution
Internal dispute resolution (IDR) is a free review of your claim by your super fund’s trustee or the insurer’s complaints team. It is handled by a different person from the original decision-maker, and you can submit additional medical evidence and a written response to the reasons letter.
Under ASIC Regulatory Guide 271, super trustees must respond to complaints within 45 days. A complaint lodged under Section 101 of the Superannuation Industry (Supervision) Act compels the trustee to formally reconsider the decision. IDR resolves a significant proportion of declined TPD claims without the need to escalate further.
3. Escalate to AFCA if internal review does not resolve the issue
The Australian Financial Complaints Authority (AFCA) is a free, independent body that handles complaints about superannuation and insurance. AFCA decisions on superannuation disputes bind the insurer and the trustee.
AFCA looks at whether the insurer applied the policy definition correctly, whether the assessment was procedurally fair, and whether unreasonable delay occurred during the claim.
4. Commence court proceedings
Court action is generally a last resort, used where IDR and AFCA have not resolved the matter or where time limits for those pathways have passed.
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What's the difference between “unlikely” and “unable” in a TPD policy?
Most TPD policies use either “unlikely ever” or “unable ever” to return to work, and the difference between those two words can decide your claim.
|
Wording in your policy |
What you need to show |
Evidence usually required |
|---|---|---|
|
Unlikely ever to return to work |
A return to work is no more than a remote possibility |
Medical evidence from your treating doctors that any return to work is unrealistic given your condition, treatment, and prognosis |
|
Unable ever to engage in any gainful occupation |
A return to work is not possible at all |
Medical evidence plus a vocational assessment ruling out other roles suited to your education, training, or experience |
An “unable” definition requires stronger evidence than an “unlikely” definition. For example, a person with chronic back pain that stops them from returning to physical work may meet an “unlikely” test on their treating doctors’ reports alone. However, under an “unable” definition, the same person would also need vocational evidence showing they cannot perform a sedentary or supervisory role.
Layer insight
The wording of the policy definition determines what you need to prove, not the severity of your condition. Phrases like “any occupation for which you are reasonably suited by education, training or experience” change the test, and the evidence supporting your claim needs to address the exact wording that applies to your policy.
How long do you have to challenge a rejected TPD claim?
The time limit to lodge a complaint with AFCA is generally two years from the insurer or super fund’s response to your internal dispute resolution complaint. And six years from the date of the insurer’s decision to commence court proceedings.
|
Pathway |
Time limit |
|---|---|
|
Internal dispute resolution (IDR) |
No fixed time limit to lodge. The fund or insurer must respond to your complaint within 45 days |
|
AFCA complaint |
Within two years of the insurer’s final decision letter |
|
Court proceedings |
Within six years of the date of the insurer’s decision, under most state limitation periods |
If you have received a procedural fairness letter, you generally have 28 days to respond before the insurer makes its final decision. Responding within that window with additional medical evidence and a written submission is often the fastest way to overturn a decision before it is finalised.
If you have already gone through internal dispute resolution, the two-year AFCA window starts on the date you receive the IDR response from the fund or insurer, not the date of the original rejection.
Expert tip
If you have missed a deadline, AFCA can accept complaints lodged outside the two-year window in limited circumstances, and older rejections can sometimes be reviewed if your circumstances or medical evidence have changed since the original decision.
What does “constructive denial” mean?
Constructive denial means the insurer does not formally decline your TPD claim, but uses delays, repeated requests for information, or unreasonable evidence demands to discourage you from continuing. There is no rejection letter, but the claim cannot progress, and you cannot access your payout.
Some of the most common signs of constructive denial include:
- Long stretches of silence between updates from the insurer
- Repeated requests for medical records that the insurer already holds
- Insurer-appointed independent medical examinations after your treating specialists have already confirmed your condition
- Requests to update earlier reports because the insurer now considers them out of date
- Repeated questions on issues already addressed in your submission.
For example, a person submits specialist reports from their treating doctor and an orthopaedic surgeon confirming they cannot return to work. The insurer requests a third independent medical examination, then a vocational assessment, then asks for updated reports because the earlier ones are now considered out of date. Months pass with no decision and no formal rejection.
Case summary
Our client was a truck driver who was injured in two motor vehicle accidents and left unable to perform the physical duties his role required. Despite detailed submissions to the super fund, the claim faced extensive delays. GMP Law filed in the Supreme Court of New South Wales, and the fund approved the claim within two weeks of the court documents being filed.
Can a TPD lawyer help with a rejected claim?
Speaking to a TPD lawyer as soon as you receive a procedural fairness letter or a formal rejection gives you the best chance of overturning the decision before it is finalised.
A TPD lawyer can:
- Review your super policy to confirm the definition that applies to your claim and the wording the insurer relied on in the rejection
- Identify the evidence needed to challenge the rejection
- Coordinate fresh medical evidence from your treating doctors and specialists, including any vocational assessments required under the policy definition
- Prepare a written submission addressing each ground of refusal point by point
- Manage communication with the insurer and respond to further requests for information
- Identify any forgotten or inactive cover across former super funds that may also support a claim.
If your TPD claim has been rejected or declined, seeking legal advice early can help you respond before the decision is finalised and give your claim the strongest chance of being overturned.
