An auto mechanic has won his claim for a disability payout after AFCA ruled an insurer failed to fairly assess his inability to work.
The claimant held a TPD policy through his superannuation fund, but stopped working after being injured in 2006. Ten years later he made an application for a TPD benefit, citing ongoing issues with his left leg and foot, and subsequently claimed for mental health problems such as anxiety and depression.
The superannuation fund’s insurer, Zurich, rejected his claim stating the mechanic could perform light work in roles such as a service adviser or delivery driver. The firm also rejected a second claim based on the claimant’s mental health, arguing his psychological conditions developed too late to be considered under the policy.
AFCA found the insurer’s decision was flawed…
AFCA found the insurer’s decision was flawed. It ruled that by 4 April 2007 – six months after the accident – the man was already permanently unfit for any job he could reasonably perform based on his experience and training.
This ruling was based on medical reports showing severe physical limitations, such as being unable to kneel, crawl, or handle heavy loads.
A 2010 vocational assessment report requested by Zurich suggested the former mechanic work as a delivery driver. However, the report noted caution would be needed with access and egress, and he would need to alternate positions to avoid stiffness in his left knee and foot.
…experts noted he struggled with customer service roles due to social anxiety
AFCA criticised Zurich for relying on ‘theoretical’ job options that weren’t realistic or available in the real world. The man’s background was mostly in manual trades, and experts noted he struggled with customer service roles due to social anxiety.
The authority also said the insurer didn’t properly consider medical evidence which supported the man’s long-term incapacity.
It found the insurer denied the complainant’s TPD claim without fairly considering the likelihood of him ever engaging in suitable employment.
As a result, Zurich has been required to pay the benefit to the trustee, plus interest dating back to March 2017, when AFCA says the claim should have been accepted.
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