CLAIMS
How claims decisions are made
We assess every claim fairly and carefully against the terms of the policy, taking each person’s circumstances into account. Claims assessors use a consistent claims framework to review the relevant information, which helps ensure decisions are fair and applied in the same way to every claim.
Why we may ask for more information
To reach a decision on a claim, we ask for relevant medical, financial, employment, and identity information. Sometimes we'll request additional details or updates over time if we need more information to make a decision. This is a normal part of assessment and helps avoid delays.
When a claim may not be approved
Sometimes a claim can't be approved because the individual circumstances don't meet the terms of the policy. While this can be disappointing, understanding the most common reasons can help clarify how the assessment decision was reached.
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. Examples include:
- “Pre‑existing condition exclusions.”
Where the illness, injury, or symptoms existed (or were present) before cover started, often within a defined look‑back period. - “Intentional self‑inflicted injury.”
This may be excluded even if death does not occur (this does not include suicide unless there is a specific suicide exclusion).
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
Your case manager will explain the reasons clearly. You can ask questions, provide additional information if it becomes available, and access the complaints pathways available to you. You also have a right to have the decision reviewed.
Your cover type matters
All claims are assessed against the terms and definitions set out in the policy. These definitions explain what needs to be met for a claim to be approved, and they differ depending on the type of cover held.
To make a fair and accurate decision, we review information from a range of sources, including medical and employment evidence.
Understand your cover type
Income Protection provides monthly payments if an illness or injury prevents someone from working and earning their usual income.
When assessing an Income Protection claim, we consider:
- Whether the condition meets the policy’s definition of illness or injury
- The person’s occupation and work duties
- Whether they were working (or actively employed) when cover commenced or changed
To support this assessment, we will:
- Verify income and employment history
- Contact the employer to understand work arrangements
- Request medical information from the treating doctor
- Ask for confirmation that the person remains unable to work, where required
TPD cover is designed to provide a lump sum payment if a person becomes totally and permanently disabled and will never return to work again.
A TPD assessment considers:
- The policy’s definition of total and permanent disability
- Whether the condition meets the required level of permanence
To help determine this, we will:
- Request medical reports from treating doctors
- Review medical history and treatment information
- Contact the employer and assess employment history
Terminal Illness cover provides early access to benefits if a person is diagnosed with a terminal medical condition and meets the policy criteria.
Claims are assessed against the policy’s terminal illness definition, including medical certification requirements and the expected prognosis outlined in the policy terms.
As part of this process, we will:
- Request medical reports confirming the diagnosis
- Contact treating specialists if additional information is needed
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.