An income protection policyholder who sought compensation following a serious car accident has lost his claims dispute after failing to show that his injuries caused him to be unable to work for more than 28 days.  

The complainant lodged a claim with TAL Life after alleging that the incident prevented him from working between April and August last year.   

The income protection policy holds a benefit that pays the insured 75% of their pre-disability monthly income if they are found to be “out of action” for a period longer than 28 days.  

But TAL refused to cover the claimant, saying that the man had not provided “relevant medical evidence” to show that he had been prevented from working for an extended period.   

The Australian Financial Complaint Authority (AFCA) acknowledges that the man had filled out forms provided by the insurer but says that the policy required him to supply medical reports signed by doctors that showed he had met the definition of “out of action”.  

AFCA notes that the complainant’s doctor, referred to as Dr U, filled out a form for a CTP claim last year, which determined the man unfit for work from May 11 to May 25 after suffering injuries to his neck and head.   

A summary of hospital records of the complainant’s injuries shows that the man had lost consciousness and experienced memory issues after hitting his head against the steering wheel of the car while also sustaining injuries to his back.   

But the ruling agreed with the insurer’s assessment of the claim, noting that an amended medical document provided by the complainant to show his unavailability appeared to be altered in a manner that was “very unusual for a doctor to change a medical certificate in that way”.  

AFCA says there was insufficient evidence to show that the insured had been unfit to work beyond the minimum 28 days required to receive the benefit.  

It also notes that the insured is paid cash in hand for his employment and says he would be required to show evidence of income should the insurer have to reassess his claim.  

“It is up to the complainant, not the insurer, to show with reliable medical evidence that he was unable to work for more than 28 days,” AFCA said.  

“He has not done that, so it would be unfair for the insurer to have to pay the claim.”  

“If the complainant provided medical evidence showing he was disabled for more than the waiting period, and if he provides reliable evidence of his income in the 12 months before his disability, the insurer should reassess the claim.”  

Click here for the ruling.