Case Spotlight: TPD Claim Approved Despite Spinal Exclusion

Graham H’s case is a clear example of how a properly prepared Total and Permanent Disablement (TPD) claim can succeed even where an insurer has applied what appears to be a significant exclusion.

Background

Graham had a long history of physically demanding employment. Over time, he developed severe and progressive spinal conditions, which ultimately forced him to cease work in July 2025. From that point onward, he was unable to return to any form of employment for which he was reasonably suited by education, training, or experience.

At the time of lodging his claim, the medical evidence confirmed widespread spinal pathology, including degenerative changes and nerve involvement, resulting in significant functional impairment and chronic pain. His condition had progressed to the point where ongoing employment was no longer sustainable.

The Complication – Spinal Exclusion

During our investigations, we identified a critical issue.

In 2017, Graham had applied to increase his insurance cover through his superannuation fund. As part of that application, he disclosed a pre-existing history of spinal issues, including spondylosis. Following that disclosure, the insurer accepted the increased cover but imposed a spinal exclusion.

This meant that any claim arising from a spinal condition could potentially be excluded from the increased portion of the cover.

The practical effect was significant. If the exclusion applied, Graham’s entitlement would have been limited to approximately $5,000 under his earlier cover. The increased cover, which formed the bulk of the insured benefit, would not respond.

On its face, this created a substantial barrier to the success of the claim.

Our Approach

A superficial assessment of the claim may have led to an assumption that the exclusion would apply and significantly limit any recovery.

However, the key issue was not simply whether Graham had a history of spinal problems, but whether the condition that ultimately caused his disablement fell within the scope of the exclusion.

We undertook a detailed review of the available medical evidence, including imaging, treating practitioner opinions, and the chronology of Graham’s symptoms.

Through that process, we identified that the pathology giving rise to his permanent incapacity was separate and distinct from the condition disclosed at the time of the 2017 application.

This distinction was critical.

We prepared comprehensive submissions addressing:

• the nature of the pre-existing condition disclosed in 2017;

• the wording and operation of the exclusion;

• the development of Graham’s condition over time; and

• the medical basis upon which the disabling condition could be differentiated from the earlier pathology.

Importantly, we addressed this issue proactively at the initial claims stage, ensuring the insurer had a clear and properly framed evidentiary basis upon which to assess the claim.

Outcome

As a result of the approach taken, the insurer accepted that the exclusion did not apply to the condition causing Graham’s disablement.

The claim was approved without the need for procedural fairness correspondence, internal review, or escalation to the Australian Financial Complaints Authority.

Graham was awarded his full TPD entitlement, totalling over $450,000.

In addition, he secured access to ongoing income protection benefits under the policy.

Key Takeaways

This case highlights several important principles relevant to TPD claims:

1. A pre-existing condition does not automatically defeat a claim. The critical question is whether the disabling condition falls within the scope of any exclusion.

2. The distinction between different pathologies, even within the same part of the body, can be determinative. Careful analysis of medical evidence is essential.

3. Early identification and proper framing of complex issues can avoid delay, dispute, and the need for escalation.

4. Many claims that appear problematic at first instance can succeed when approached strategically and supported by the right evidence.

   
   

Conclusion

Graham’s case demonstrates the importance of not accepting an insurer’s position at face value, particularly where exclusions are involved.

With the right approach, it is often possible to navigate around apparent barriers and secure a full entitlement under the policy.

If you are unsure about your TPD cover, or have been told your claim may be impacted by a pre-existing condition or exclusion, it is worth obtaining proper advice before making any assumptions about your entitlements.

Mohammed Kheir

Principal

MK Allan Lawyers