CLAIMS
How claims decisions are made
Making a claim often comes at a time when life feels uncertain or overwhelming. We understand that, and we want you to know that each claim is considered with care, respect, and empathy. We take the time to look at each claim carefully, based on the terms of your policy and your individual circumstances.
Our aim is to understand your situation as a whole using a consistent framework, so we can make a fair decision. Throughout this process, our focus is on supporting you and keeping things as clear as possible.
Why we may ask for more information
To help us reach a decision on your claim, we ask for relevant medical, financial, employment, and identity information. Sometimes, we need a little more detail to fully understand your situation.
This can mean checking in with you more than once or asking for updates over time. While this is a normal part of the process, we know it can feel difficult when you’re already coping with a lot. If we do need anything further, we’ll explain why and guide you through what happens next — and we’ll support you at every step.
When a claim may not be approved
Sometimes a claim can’t be approved because it doesn’t meet the terms set out in the policy. We understand how hard it can be to read about this part of the process, especially if the outcome isn’t what you were hoping for.
The information below explains some of the most common reasons a claim may not be approved. This is formal, legal wording, and while it can feel quite technical, it’s meant to help explain how decisions are made and why they’re reached. If you're unsure about any of the below examples, please get in touch with us and we can talk you through it.
1. The claim doesn’t meet a policy or claim type definition.
This means the situation being claimed for isn’t covered in the way the policy defines that benefit.
2. The person isn't eligible for a benefit.
This can happen in a few specific scenarios, such as:
- “Cover ceased due to Protecting Your Super legislation.”
For example, where a superannuation account became inactive and insurance cover stopped. - “The person making a claim was not At Work or in Active Employment when cover commenced, recommenced, or increased.”
In simple terms, this usually means the person wasn’t working their usual duties and hours, or was away from work due to illness or injury, at the time their cover began or changed.
3. An exclusion applies.
This is a specific circumstance or cause where a benefit isn’t payable, even when cover is otherwise in place. These are applied strictly in line with the policy wording and are commonly used to manage known or heightened risks. For example, “pre‑existing condition exclusions” are where illness, injury, or symptoms existed (or were present) before cover started, often within a defined look‑back period.
4. There isn't enough evidence available to confirm the policy terms are met.
In some cases, there may not be enough medical or supporting information to complete a full assessment. When this happens, additional details may be requested to help us review the claim thoroughly and fairly.
If you disagree with a decision
We understand this can be difficult. Your case manager is here to listen, explain the decision, answer your questions, and support you with the options available to you, such as making a complaint or asking for the decision to be reviewed.
Your cover type matters
We know policy terms can feel confusing, especially during a stressful time. Each type of cover has its own definitions, which guide how claims are assessed. To make a fair and careful decision, we look at information from different sources, including your doctor and employer, to help us understand your individual situation.
Understand your cover type
When we assess an Income Protection claim, our focus is on understanding how your health is affecting your ability to do your work. This includes looking at how your condition fits within the policy, what your role involves day-to-day, and your work situation when your cover began or changed.
To help us assess your claim, we will:
- Confirm income and employment history
- Speak with your employer to understand work arrangements
- Request medical information from your treating doctor
- Check in from time to time, where needed, to confirm you’re still unable to work
We know illness or injury can bring a lot of change and uncertainty. TPD cover is there to help ease financial pressure if a serious illness or injury means you’re permanently unable to work again.
Because TPD can be defined differently depending on your policy, the wording in your Product Disclosure Statement (PDS) matters a lot. It explains how TPD applies to your cover and what needs to be met to make a claim.
To help us assess each claim fairly, we will:
- Request medical reports from your treating doctors
- Review medical history and treatment information
- Speak with your employer to understand employment history
We know this can feel like a lot, especially when you’re unwell. Our aim is always to approach this process with care, take the time to understand your situation properly, and support you throughout.
If you or someone you're close to has been diagnosed with a terminal illness, we know this is an incredibly challenging and emotional time, and that dealing with insurance may feel like the last thing you want to think about. Terminal Illness cover is there to help ease some of the financial pressure, so you can focus on what matters most.
When a Terminal Illness claim is assessed, the focus is simply on whether the medical information meets the policy definition. Our role is to apply the policy with care, respect, and compassion, while supporting you each step of the way.
To help us move things forward, we’ll request some information, including:
- Medical details: We’ll ask the doctors and specialists who know your situation best for their reports confirming your diagnosis and prognosis.
- Additional medical opinions: In some cases, we may need an additional medical opinion to help clarify information. If this is needed, we’ll explain why, organise everything for you, and cover the cost, so it’s one less thing for you to worry about.
Other guides available for you
If you’re off work dealing with illness or injury and unsure what to do next, we’re here to help you explore your options.
I’m helping someone with a claim →
Guidance and resources if you’re supporting someone else through their claim.
When you need extra assistance or support →
There are many reasons you might need extra assistance, for example if you’re living with a disability, facing family or domestic violence, struggling to request important documents, or if English isn't your first language.