Case Study – Any Occupation TPD

In this claims case study, the adviser tells how she stepped in to help the client receive the TPD benefit they were entitled to through an industry super fund. It highlights the complexity of claims for group insurance inside superannuation, particularly when looking at the ‘any’ versus ‘own’ occupation definition.

[hr]

At a glance

In 2009 I met with a husband and wife for a financial planning meeting in my office. During the meeting, Barbara, a school teacher, advised that she was severely injured in a tour bus accident in Italy five years previously. As a result of the accident, Barbara required continuous ongoing treatment and had only been able to teach on a casual basis. Recently, her condition had worsened and she had developed a serious, debilitating form of arthritis, to the point where she could no longer work.

In that meeting I learnt that, at the time of the accident, Barbara had ‘any occupation’ TPD cover under an industry superannuation fund. Naturally, I enquired whether the industry fund had offered her any assistance during the previous five-year period.

Barbara advised that she had originally made enquiries through the fund’s Customer Service department about what her options were, and had been told the insurance would stay in place even if her employer was not paying into her super fund. There was no mention of how to claim, or indeed if they could refer her to someone who could assist.

After hearing her story in our first meeting, I commenced enquiries with the fund as to how I could assist with what looked like a TPD claim.

The industry fund had changed insurers three times since Barbara’s accident, and this potential claim became a ‘hot potato’ – a  little like musical chairs with all the insurers hoping the claim would not ‘land on them’. You can imagine the questions each claims manager asked in an attempt to determine when Barbara had in fact finished work, and whether she had returned to work at any time over their responsibility period.

This claim was also hampered by the fact that Barbara had not ‘thrown in the towel’ when she was first injured; she had kept trying to return to work due to her strong work ethic and her need to feel she was not disabled.

We had to obtain a statutory declaration from her school’s Principal (now retired), confirming Barbara had eventually transitioned from full-time to part-time, and then to casual employment. It was managed this way because the school did not want to lose an excellent, dedicated teacher. (Sometimes the evidence for claim is not just about the physical health of the client!)

The three-year struggle came to an end with the industry fund recently agreeing to pay her claim.

I believe our credibility as financial advisers stands or falls at claim time. Over the last three years the professional relationship I have built with Barbara’s husband, an accountant, has generated many referrals; not the least of which was his own cover, including the buy sell insurance of the partnership he was in.

Whilst the claim work has been ‘gratis’, I was able to retain Barbara and her husband as clients, and have built a long-term relationship.

As an aside, when I visited the specialist with this client for her ‘independent medical assessment’ I was told that in the 30 plus years he had been in practice, the specialist had not seen another financial adviser attend a claimant’s meeting. I have also been told by claims managers that less than 20% of advisers are involved in the claims process. How can this be?

I believe turning people from prospects to clients is not just a sales transaction – we must be there when they need us. Our integrity is at stake!

*The client’s name has been changed to protect their privacy