Understanding how a TPD insurer reviews your claim — and the specific ways they might challenge it — helps you prepare an evidence package that anticipates and answers every concern before they raise it.
The multi-stage review process
Most insurers put TPD claims through multiple assessment layers:
- Initial assessment — completeness check, basic eligibility, waiting period
- Medical review — often conducted by an in-house or contracted medical officer
- Claims committee — for larger or complex claims, a committee reviews the recommendation
- Trustee decision — for super fund TPD, the fund trustee makes the final call, not the insurer
What insurers scrutinise most
- Permanence — is your condition truly permanent? Insurers look for evidence of treatment trials, specialist prognosis, and why recovery is unlikely
- Consistency — are your medical records, claim form and employment history telling the same story? Inconsistencies are flagged and explored
- Alternative occupations — particularly for any-occupation definitions, the insurer assesses whether you could work in any role suited to your background
- Policy exclusions — they will check whether a pre-existing condition exclusion applies
Independent Medical Examinations (IMEs)
Insurers may request you attend an IME — an assessment by a specialist of their choosing. IME doctors are not independent in the true sense — they are paid by the insurer. If an IME report is unfavourable, your own treating specialist can provide a rebuttal. See our IME guide.
Respond, don't react
When an insurer queries your claim or requests further information, respond with targeted, well-evidenced answers. Each response is an opportunity to strengthen your position. Check your claim strength with a free eligibility check.