When a total and permanent disability claim in super is declined: the stages that come after

A declined claim is a decision made under one policy's rules, at one point in time. It is often not the end of the road. There are set stages after a decline, and each one does a different job.

This page explains how those stages generally work for TPD cover held inside superannuation (super). It does not say whether any decision was right. It is not a view on anyone's claim. If you want the short version first, start at My claim was declined.

The short version

After a TPD claim in super is declined, these stages generally exist:

1. The reasons letter, and asking for the documents behind it.
2. Asking the insurer to reconsider, usually with more information.
3. A complaint to the insurer or to the fund's trustee.
4. A complaint to AFCA, which is free.
5. Talking to a specialist firm that handles declined claims.

They are not a ladder that has to be climbed in order. Some of them overlap. One timing point runs underneath all of them: AFCA's time limits for TPD complaints in super run from the date of the first decision. That is set out further down, in AFCA's own terms.

Stage 1: the reasons letter

Most of what follows depends on the reasons. They show what the decision turned on.

The Life Insurance Code of Practice (the Life Code) is the life insurance industry's own code. Insurers that subscribe to it commit to its standards. Under it, when an insurer declines a claim, it commits to tell you in writing:

• its reasons, and a summary of the information it relied on
• that you can ask for copies of the documents it relied on, which it will send within 10 business days of a request, to you or to your doctor if it thinks that is more appropriate
• that you can ask it to review the decision, or give it more information to consider
• how to make a complaint

(Life Code cl 5.58.)

If the insurer arranged a medical examination as part of the claim, you can ask for a copy of that report too. The Code says the insurer will send it to you, or to your doctor if it thinks that is more appropriate (cl 5.23).

Two limits on the Code are worth knowing. First, it is a promise insurers make to their industry body. It does not give anyone rights they can enforce in court (cl 8.6 and 8.10), although AFCA can take it into account when deciding a complaint (cl 8.9). Second, it does not apply to super trustees unless a trustee has chosen to adopt it (cl 1.10).

The Code has also been reviewed. The review's Final Report, dated 30 June 2026, recommends changes, but they are not part of the Code yet. This page describes the version in force from 1 March 2025. For what the review recommends, see the Life Code review's Final Report.

If the wording of a decline letter is hard to follow, the letter decoder explains common phrases in plain English.

Who the letter names as the decision-maker

TPD cover in super is usually held under a group policy. That policy is often owned by the fund's trustee, the company that runs the fund. The insurer assesses the claim. The Life Code says that where a trustee owns the policy, the insurer communicates with the trustee, who passes things on to the member as needed (cl 3.3).

So a decline letter can come from the insurer, the trustee, or both. This matters later. AFCA's guidelines say that where a trustee declines a TPD claim because the group insurer declined to pay, the trustee is still the decision-maker, and a complaint to AFCA is made against the trustee. AFCA's time limits are written around who made the decision.

For how the fund, the trustee and the insurer fit together, see Insurance inside super, explained.

Stage 2: asking the insurer to reconsider

The Life Code lets a person, or the policy owner, ask the insurer to reopen or reassess a claim it has declined (cl 5.57). The Code sets no deadline for asking. The insurer decides whether to agree. If it does, the claim gets a new received date, and the Code's timeframes start again.

A reconsideration usually turns on information. The reasons letter shows what the insurer relied on. A person's own treating doctor may see the medical picture differently from the insurer's examiner, and can say so in their own words. Whatever a treating doctor writes is their own opinion to give.

One thing a reconsideration does not do. AFCA's guidelines say that asking the decision-maker to reconsider, or giving it new information, does not change the start date of AFCA's time limits for a TPD complaint. More on that below.

Stage 3: a complaint to the insurer or the trustee

A complaint is a separate step from asking for a reconsideration. For insurance held in super, a complaint can go to the insurer or to the trustee (Life Code cl 7.16).

The Australian Securities and Investments Commission (ASIC) sets standards for how firms handle complaints, in its Regulatory Guide (RG) 271. It says a complaint about insurance in super can be lodged with either the insurer or the trustee, and the clock starts on the date it is first lodged with either one (RG 271.79).

RG 271 sets maximum times for a written response (Table 2):

• most complaints: 30 calendar days
• complaints to super trustees, other than about death benefits: 45 calendar days

RG 271 deals with complaints about insurance in super under its heading on super trustee complaints. If it is not clear which timeframe applies, the firm can say which one it is working to.

A firm can go past the maximum only if the complaint is particularly complex, or if circumstances beyond its control are causing delay (RG 271.65). Even then, it must send a delay notice before the time runs out. The notice gives the reasons for the delay, the right to go to AFCA, and AFCA's contact details (RG 271.66).

The firm's final written response must give the outcome of the complaint, the right to take it to AFCA, and AFCA's contact details (RG 271.53). AFCA's own Rules describe a firm's final response as one that also states the time limit for going to AFCA. A final response may or may not state that limit. If it does not, AFCA can say what applies.

For what the regulators' own data shows about delay in claims handling, see When a claim stops moving.

Stage 4: a complaint to AFCA

AFCA is the external complaints body for financial firms, including insurers and super trustees. It is free for the people who complain to it (AFCA Rules A.1.3). Using it is not compulsory. A person can go to court or another forum instead (A.1.4). AFCA's website is afca.org.au.

When a complaint arrives, AFCA will usually refer it back to the firm first, and set a timeframe for the firm to resolve it or state its position. It may skip that step if it thinks it should start investigating straight away (A.5.2).

For a TPD complaint against a trustee where a group insurer made the underlying call, AFCA's guidelines say it will generally join the insurer to the complaint, so both can be dealt with at once.

AFCA does not promise an outcome, and nothing on this page predicts one.

AFCA's time limits for TPD in super, in AFCA's words

These are different from the response times above. Those are about how long a firm has to answer a complaint. These are about when a complaint can be taken to AFCA.

This section reports what AFCA's published Rules and guidelines say. It does not say how any limit applies to anyone. AFCA can answer that, and so can a lawyer.

For a complaint about a trustee's decision on a TPD benefit, or a decision by certain other super providers, AFCA's Rules set out two cases (B.4.1.1):

• If the person permanently ceased employment because of the physical or mental condition behind the claim: the claim must have been made within two years of permanently ceasing employment, and the complaint lodged with AFCA within four years of the decision.
• If the person did not permanently cease employment because of that condition: the complaint must be lodged with AFCA within six years of the decision.

Three more points, from the Rules and AFCA's Operational Guidelines (pages 111 and 112).

The limits run from the first decision. The guidelines say the date of the decision is the date of the first, or original, decision to deny the TPD claim. If that decision is later confirmed, varied or replaced after a complaint, it is treated as made when the original was (Rules B.4.1.2). Asking for a reconsideration does not move that date.

Employment ends at formal termination. For the two-year claim limit, the guidelines say the date runs from when employment is formally terminated, not the last day a person was able to work. Some employers keep a person on the books for a while to see whether they recover. AFCA still counts from the formal end.

AFCA will not extend these limits. That is in the Rules (B.4.4.1).

The guidelines add one more thing. If a complaint against the trustee falls outside these limits, AFCA may be able to accept a complaint against the insurer under its general jurisdiction, where different time limits apply. Whether that is possible in any particular case is a question for AFCA.

If a fresh claim has been made after a decline, how that affects these limits is also a question to put to AFCA or a lawyer.

Other cover, other limits

The limits above are for TPD complaints about super decisions. Income protection, and TPD cover held outside super, can fall under different AFCA limits, which this page does not set out.

A decline under one policy also does not decide what any other cover might do. Cover through a second super fund, or a policy held outside super, is assessed under its own terms. See how to find out what cover you hold and TPD cover in your super.

Stage 5: a specialist firm

A specialist firm that handles declined TPD claims can read the decision against the policy wording and the evidence. A lawyer can say how the rules apply to a particular situation. Declined claims are a specialist area, and it is one the firms on our panel work in. Community legal services also help with insurance disputes.

Firms on the ClaimsGuide panel work on a no-win-no-fee basis. Any firm should explain its fees in writing before anything is agreed, including what it charges if a claim succeeds and what costs could still fall to the client. How ClaimsGuide itself is paid is set out on how we get paid.

Dates worth having in one place

Whoever you end up talking to, these tend to come up:

• the date employment formally ended, if it has
• the date the claim was made
• the date of the first decline letter
• who the letter names as the decision-maker
• the date any complaint was lodged, and with whom
• any final response from the insurer or the trustee

ClaimsGuide does not run claims or assess anyone's entitlements. We explain how the system works, in plain English, and connect people with specialist firms when that would help.

If you want to talk any of this through, we'll explain which doors exist for your situation and, if you want, introduce you to a firm on our panel. It costs you nothing.

Sources

• Council of Australian Life Insurers, Life Insurance Code of Practice, in force from 1 March 2025. Clauses 1.10, 3.3, 5.23, 5.57, 5.58, 7.16, 8.6, 8.9 and 8.10.
• Australian Securities and Investments Commission, Regulatory Guide 271: Internal dispute resolution, issued 2 September 2021. RG 271.53, RG 271.65, RG 271.66, RG 271.79 and Table 2.
• Australian Financial Complaints Authority, AFCA Rules, approved version released 8 October 2026. Rules A.1.3, A.1.4, A.5.2, B.4.1.1, B.4.1.2, B.4.4.1, and the definition of a firm's final response.
• Australian Financial Complaints Authority, Operational Guidelines to the AFCA Rules, effective 8 October 2026, pages 111 and 112.