Claim Story: $2,800,000 TPD Payout

Client Profile

Age: 50 years old

Occupation: Professional with management experience

Condition: Major Depressive Disorder, Anxiety, and complex PTSD

Claim Type: Any Occupation TPD

Benefit Amount: $2,800,000.00

Case Background

A 50-year-old professional, was diagnosed with severe psychological conditions that significantly impacted her ability to work. Despite being certified unfit for work in August 2020, she persevered until September 2020 when her condition made continued employment impossible.

The client's policy included an "Any Occupation TPD" definition, requiring evidence that she would be unlikely to ever engage in any occupation suited to her education, training, or experience that could generate at least 25% of her pre-disability income.

Medical Evidence

The claim was supported by comprehensive medical documentation from multiple healthcare professionals:

1.General Practitioner (Dr. R): Documented ongoing symptoms including panic attacks, low mood, anxiety, poor sleep, night terrors, and significant fatigue. The GP noted substantial impairment in performing routine domestic duties.

2.Psychologist: Confirmed the client "continues to suffer with extreme anxiety, depression, panic and symptoms of PTSD" in their November 2024 assessment.

3.Treating Psychiatrist (Dr. G): Provided extensive clinical notes documenting persistent symptoms of anxiety, sleeplessness, low mood, feelings of overwhelm, and chronic fatigue over a four-year treatment period.

Vocational Assessment

A Transferrable Skills Assessment (TSA) was conducted to identify potential alternative occupations suited to the client's education, training, and experience. However, Dr. G's May 2025 report conclusively stated:

"Ms. ML does not have capacity to work in any of these roles due to her psychological condition. She would be able to work part time in any of these roles, and would not be able to do full time despite vocational rehabilitation support. These roles are of high pressure and intensity, high responsibility and she would not be able to cope with the demands of these roles as well as not be able to switch off from managing these roles. The environment and pressure she would be put under would cause her mental health to be at further risk of deterioration."

Claim Resolution

After thorough review of the medical evidence, the insurer determined:

1.The treating psychiatrist had been providing consistent care for four years with detailed documentation showing no improvement in the client's condition despite ongoing treatment.

2.Dr. G's professional opinion carried significant weight due to the long-term treatment relationship and comprehensive understanding of the client's condition.

3.The psychiatrist provided sound rationale explaining why the client had reached maximum medical improvement and why her condition would prevent her from performing even alternative occupations identified in the TSA.

4.The consistent medical opinions across multiple healthcare providers (GP, psychologist, and psychiatrist) presented compelling evidence supporting the claim.

Based on this evidence, the insurer determined an Independent Medical Examination (IME) was unnecessary and approved the claim for the full benefit amount of $2,800,000.00, calculated as of the date of disablement in December 2020 (three months following cessation of work).

Key Insights

This case highlights several important aspects of successful TPD claims:

1.Specialist Opinion Weight: A treating specialist's professional opinion carries substantial weight, particularly when they have an established treatment history with the client and provide detailed rationale for their conclusions.

2.Consistent Documentation: The four-year treatment history with consistent symptoms and lack of improvement, despite appropriate interventions, provided compelling evidence of permanent disability.

3.Vocational Assessment Response: The specialist's specific response addressing why the client could not perform alternative roles identified in the TSA was crucial to claim approval.

4.Aligned Medical Opinions: Consistent documentation across multiple healthcare providers (GP, psychologist, and psychiatrist) strengthened the claim's validity.

5.Maximum Medical Improvement: Evidence that the client had reached a stable baseline with little chance of significant improvement despite ongoing treatment was a determining factor.

This case demonstrates how comprehensive medical documentation, specialist opinions, and proper claim preparation can lead to successful outcomes for clients facing genuine permanent disabilities.