In mental health TPD claims, the main issue is often not whether the person has a genuine condition. The issue is whether the evidence properly explains how that condition affects their ability to work.
Depression, PTSD, anxiety, bipolar disorder and other psychiatric conditions can seriously affect a person’s life. Insurers usually understand that. But they may still reject or question a claim if the evidence does not prove the person is unlikely to return to work under the wording of the TPD policy.
That is why a diagnosis on its own is usually not enough.
A diagnosis explains what condition the person has. A TPD claim usually needs to go further and explain what that condition means for the person’s work capacity, day-to-day functioning and future ability to earn a living.
Why Mental Health TPD Claims Can Be Difficult
Mental health TPD claims can be harder to prove because symptoms are not always visible.
A person may look calm during an appointment, be able to attend a short meeting, or manage basic daily tasks, but still be unable to cope with the demands of regular employment.
ASIC’s review of TPD insurance claims found that mental illness-related claims had the highest decline rate among the groups it examined, at 16.9%. That does not mean these claims cannot succeed but itdoes show why the evidence needs to be prepared carefully.
The insurer is not just asking, “Is this person unwell?” It is usually asking: does the evidence show this person is unlikely to return to work for which they are reasonably suited by education, training or experience?
Capacity Is Not the Same as Symptoms
Medical records often describe symptoms in detail. They may mention poor sleep, panic attacks, low mood, intrusive thoughts, medication side effects, trouble concentrating, emotional distress or difficulty leaving the house. Those details matter, but they may not answer the insurer’s main question.
The insurer will often want to know whether the person can:
- attend work reliably
- concentrate for long enough
- complete tasks at a normal pace
- cope with pressure
- deal with managers, co-workers or customers
- manage change
- make decisions
- stay regulated through a normal workday
- keep doing those things over time
For example, a person may be able to attend medical appointments once a fortnight, but that does not mean they can work five days a week.
A person may be able to shop for groceries on a good day, but that does not mean they can handle workplace deadlines, supervision, customer contact or regular attendance.
The Policy Definition Matters
TPD cover depends heavily on the wording of the insurance policy.
Some TPD policies use an own occupation test, while others use an any occupation test.
An own occupation test usually looks at whether the person is unable to return to the job they were doing before their disability.
An any occupation test is usually harder. It looks at whether the person is unable to return to any work reasonably suited to their education, training or experience.
For example, a nurse with severe PTSD may not be able to return to a hospital role. Under an own occupation definition, that may be the central issue.
But under an any occupation definition, the insurer may ask whether that person could do another type of work, such as administration, telehealth support, training, or a less demanding health-related role. The claim then needs evidence explaining why those alternatives are not realistic, given the person’s psychiatric condition.
Practical Examples
A person with severe depression may be able to shower, prepare simple meals and attend occasional appointments. But they may still be unable to maintain reliable attendance, manage fatigue, make decisions, or cope with work pressure.
A person with PTSD may be able to speak calmly in a medical appointment but become overwhelmed by noise, conflict, authority figures, crowded environments or unexpected change in a workplace.
A person with bipolar disorder may have periods where they appear more stable, but still experience relapse patterns, medication changes, hospital admissions or mood instability that make regular employment unrealistic.
These examples show why insurers should not rely too heavily on isolated daily activities. Everyday survival is not the same as sustained work capacity. In any case, the TPD definition under the relevant policy is what matters most.
Why Insurers May Overstate Capacity
Insurers sometimes point to small parts of a person’s life and argue that those activities show they can work.
They may refer to driving, shopping, attending appointments, caring for children, exercising, using a computer, or seeing friends occasionally. Those activities may be relevant, but they do not automatically prove work capacity.
A person may be able to do short, flexible tasks at home but still be unable to meet the demands of a real job. Work usually requires reliability, pace, attendance, concentration, communication, stress tolerance and consistency over many weeks or months.
For mental health claims, that distinction is very important.
Vocational Evidence Can Help
Medical evidence is important, but vocational evidence can also be useful.
Vocational evidence looks at the person’s work history, skills, training, education and realistic job options. It can help answer whether the jobs suggested by the insurer are actually suitable.
For example, an insurer may say a former construction supervisor could move into office administration. But if the person has severe anxiety, poor concentration, low tolerance for pressure, limited computer skills and no recent office experience, that suggestion may not be realistic.
A vocational assessment can help connect the medical limitations to real-world employability.
What Strong Evidence Usually Shows
A well-prepared mental health TPD claim usually brings the evidence together clearly.
It should show:
- the diagnosis and treatment history
- how long the condition has affected the person
- what treatment has been tried
- whether there have been relapses or failed returns to work
- how symptoms affect work-related function
- why the person cannot meet normal work demands
- why alternative work is not realistic under the policy definition
- why the incapacity is likely to continue
The goal is not to overwhelm the insurer with hundreds of pages of medical notes. The goal is to answer the exact question the policy asks.
The Strongest Claims Link Medicine to Real Work
Mental health TPD claims are strongest when the medical evidence and work evidence fit together.
The psychiatrist explains the condition, treatment history and prognosis. The employment evidence explains what the person’s job required and why it became impossible. The vocational evidence, if needed, explains why other suggested work is not realistic.
That approach is stronger than simply saying the person is distressed, unwell or unable to return to their old role.
The insurer needs to understand why the person cannot sustain work in practical, long-term employment terms.
Getting Legal Help Can Make a Difference
Mental health TPD claims can become difficult because insurers often focus closely on policy wording, capacity assessments and selected parts of medical records.
A lawyer can help identify the real issue in dispute, gather the right psychiatric and vocational evidence, and present the claim in a way that directly addresses the insurer’s definition of disability.
Law Advice assists clients with mental health TPD claims by reviewing the policy wording, identifying evidence gaps, and building a claim that explains work capacity properly.
Where a claim has been delayed, questioned or declined, experienced legal guidance can help strengthen the evidence and improve the prospects of securing the TPD benefits the claimant is entitled to pursue.