TPD Claim Denied 'Unlikely to Ever Work Again': What It Means and What to Do Next

Receiving a denial letter after a TPD claim is one of the most distressing outcomes you can face when you're already dealing with a serious illness or injury. And when the reason given is that you don't meet the "unlikely to ever work again" test, it can feel final, as if the insurer has made a definitive judgement about your entire future.

It isn't final. And in many cases, the denial is wrong.

The "unlikely to ever work again" standard is frequently misapplied by insurers. It is a legal test with specific meaning under Australian law, and challenging an insurer's interpretation of it is one of the most successful avenues for TPD claim appeals.

This guide explains what the standard actually means, why denials on this basis are often disputable, and what your options are when your TPD claim has been rejected.

50% of Australians don't know their superannuation includes insurance cover, which means many who receive a denial also do not know they have the right to challenge it.

Over $1 billion in super insurance benefits goes unclaimed in Australia every year. Many involve TPD claims denied on this ground that were never challenged. The average approved TPD payout in Australia is $440,000.

Many TPD denials on the "unlikely to ever work again" grounds are based on incorrect or incomplete application of the legal test. An independent review of your claim by a specialist is the most important step you can take after a denial.

What "Unlikely to Ever Work Again" Actually Means

This phrase appears in the TPD definitions used by most Australian super funds. The exact wording varies, but the "any occupation" definition typically reads something like:

"The member is unlikely, because of illness or injury, to ever engage in or work for reward in any occupation for which they are reasonably qualified by education, training, or experience."

There are two critically important words here: "unlikely" and "reasonably".

"Unlikely" is not "impossible"

The standard is not that you must be physically incapable of ever performing any work under any circumstances imaginable. The question is whether, based on the medical evidence available at the time of assessment, your recovery and return to work is unlikely.

Insurers sometimes apply this standard as if it means "the member could never lift a box or type at a keyboard under any conceivable future scenario." That is not what the law requires.

The question is a probability assessment: given your diagnosis, prognosis, treatment history, and functional capacity, is it more probable that you will not return to suitable work than that you will?

"Reasonably qualified" limits the scope of occupations considered

The standard does not require you to be unable to work in every possible role in the economy. It requires that you be unable to work in occupations for which you are reasonably qualified by your actual education, training, and experience.

This means:

• A 55-year-old former tradesperson with chronic spinal injuries is not required to be able to work as a data entry clerk

• A former high school teacher with severe PTSD is not required to be theoretically able to work as a night watchman

• The occupations considered must be ones the person could realistically enter given their background

Insurers who deny claims by pointing to theoretical low-skill roles the claimant has no background in are misapplying the definition.

Why TPD Claims Are Denied on This Ground

There are several common reasons insurers deny on the "unlikely to ever work again" standard:

1. Insufficient or incomplete medical evidence

The insurer's decision is only as good as the evidence before them. If your medical evidence doesn't clearly address permanence and work capacity in the language of the TPD definition, the insurer may conclude the threshold isn't met.

Fix: Obtain updated specialist reports that directly address the "unlikely to ever" standard.

2. Reliance on an independent medical examination (IME)

Insurers regularly arrange their own IME with a medical specialist of their choosing. These reports are sometimes written in ways that favour a denial. An IME report that concludes you have "some capacity for light duties" can be used to justify a denial.

Fix: Challenge the IME report with evidence from your own treating specialists. If the IME specialist's opinion is inconsistent with your clinical history, that inconsistency can be raised in an appeal or AFCA complaint.

3. Applying the wrong occupation scope

As above, the insurer may be considering a broader range of occupations than is legally required under your policy.

Fix: Obtain a legal or specialist review of the insurer's decision letter to identify whether the correct legal test was applied.

4. Mischaracterising your functional capacity

The insurer may have placed excessive weight on a brief period of symptom improvement, a single specialist's report, or an activity you performed (social, recreational, or part-time) as evidence that you are capable of sustained employment.

Fix: Provide clinical evidence establishing the difference between occasional activity and sustained work capacity, including evidence of symptom fluctuation and the impact of work-like activity on your condition.

What to Do When Your TPD Claim Is Denied

Step 1: Get a copy of the full decision and file

You have the right to request a copy of the insurer's decision, the evidence they relied on, and the basis for their conclusion. Request this in writing from your super fund immediately.

Step 2: Review the decision letter carefully

The denial letter should explain:

• Which definition was applied

• What evidence was considered

• Why the insurer concluded the definition was not met

Look for: incorrect application of the occupation scope, reliance on an IME that contradicts your treating specialists, or failure to consider all your conditions together.

Step 3: Obtain updated medical evidence

If the denial was based on insufficient evidence of permanence or work incapacity, updated specialist reports that explicitly address the TPD standard can change the outcome.

Step 4: Lodge an internal appeal with the insurer/fund

Most insurers and super funds have a formal internal dispute resolution (IDR) process. You can lodge a written appeal with additional evidence. The fund is required to respond within 45 days (for superannuation complaints under the IDR rules).

Step 5: Lodge a complaint with AFCA

If your internal appeal is unsuccessful, you can lodge a complaint with the Australian Financial Complaints Authority (AFCA) at afca.org.au. AFCA is a free external dispute resolution service with the power to overturn insurer decisions.

AFCA handles a significant volume of TPD claim disputes each year. A material proportion of those complaints result in outcomes favourable to claimants, including claims that were initially denied.

AFCA complaints must generally be lodged within two years of the insurer's final decision.

Step 6: Consider legal proceedings

If AFCA does not resolve the matter or if your circumstances are complex, legal proceedings in a court may be an option. This is typically a last resort, but Better Claim has access to legal practitioners who specialise in super insurance disputes.

What Evidence Strengthens a TPD Appeal

Strong appeal evidence typically includes:

• Updated specialist reports explicitly addressing the "unlikely to ever" standard

• Evidence from multiple specialists supporting consistency in your diagnosis and prognosis

• Functional capacity evaluations conducted by occupational therapists

• Vocational assessments addressing what occupations you are and are not qualified for, and whether any are accessible given your limitations

• Evidence rebutting specific points raised in the insurer's IME (where the IME doctor's conclusions are inconsistent with your treating team's assessments)

Don't Accept a Denial at Face Value

This is important. A denial is not the end of the process. It is the beginning of a dispute.

In Australia, the super insurance claims and disputes framework provides multiple avenues for review: internal appeal, AFCA, and the courts. Insurers know this. Many initial denials are tested on appeal, and outcomes can change significantly when proper evidence is obtained and the correct legal standard is applied.

Better Claim works with claimants whose claims have been denied, not just those lodging for the first time. If you have received a denial, Contact Better Claim for a Free Case Review →

How Better Claim Can Help

Better Claim handles denied TPD claims on a no-win, no-fee basis. We review your denial letter, assess the strength of your appeal grounds, identify the evidence needed, and manage the AFCA process or legal escalation where required.

You don't pay unless we get you a result. Start Your Free Case Review → or Check Your Eligibility - It's Free →

Frequently Asked Questions

How long do I have to appeal a TPD denial?

You should lodge an internal appeal with the insurer or fund promptly after receiving the denial. For AFCA complaints, you generally have two years from the insurer's final decision. Do not delay.

What does "any occupation" mean in practice for an appeal?

"Any occupation" means occupations for which you are reasonably qualified by your education, training, and experience. An insurer who denies your claim by pointing to occupations you have no background in is applying the definition too broadly. This is a common grounds for successful appeal.

What if the insurer arranged an IME that concluded I can work?

An insurer-arranged IME is not the final word. You can challenge it with your own specialist reports. AFCA regularly considers competing medical opinions and can prefer your treating specialists' views over an insurer IME where the clinical evidence supports it.

Can I make a fresh claim after a denial?

In some circumstances, yes. If new medical evidence establishes that your condition has deteriorated or is now clearly permanent, you may be able to re-lodge. Seek specialist advice about whether a fresh claim or an appeal is the better path.

Is it worth getting a claims specialist involved after a denial?

Yes. A denied claim that is taken to AFCA with proper evidence and legal analysis has a meaningful chance of reversal. Attempting to navigate this process alone, against an insurer with legal resources, significantly disadvantages you.

Does Better Claim charge for reviewing denied claims?

No. Better Claim reviews denied claims for free as part of our eligibility assessment. If we take your case, we work on no-win, no-fee terms. Start Your Free Case Review →

Resources

• AFCA: Free external dispute resolution for super insurance denials (lodge online)

• ASIC MoneySmart: What to do if your insurance claim is denied

• Australian Human Rights Commission: Disability rights in Australia

• Legal Aid (state-based): Free legal advice services available in each state if needed

This article is intended as general information only and does not constitute legal or financial advice. TPD appeal rights and timeframes vary. Better Claim recommends seeking professional advice specific to your denial circumstances as soon as possible. For free case review of a denied TPD claim, contact Better Claim.