A part-time cabinetmaker who lodged an unsuccessful income protection (IP) claim after suffering a head injury at work has lost his dispute over insurer TAL’s decision to reject his claim for providing insufficient information to show he was working for more than 20 hours a week before the injury.  

The man was also unable to produce medical documents to certify he was incapable of performing two out of five regular daily activities after the injury in September 2020. Examples of regular daily activities include cooking, driving and grocery shopping. 

The TAL policy pays a benefit if the complainant meets the “out of action” criteria. In this case the complainant was required to show he is unable to engage in his usual occupation or is working less than 20 hours a week and unable to perform two or more daily tasks without assistance or using special equipment. 

The claimant’s initial claim dated March 2 2021 shows he was working on light duties as a contractor and part-time cabinetmaker for his son before his injury. He had been performing these duties for 39 years and the average number of hours spent per week over the previous 12 months was seven hours over 10 weeks. 

The insurer asked for more information to determine if he worked more than 20 hours per week before the injury. But the additional details provided did not indicate whether the payments were work-related. 

“The information provided does not establish that the claimed head injury meets the policy terms and conditions,” the Australian Financial Complaints Authority (AFCA) ruled. 

“Therefore, the complainant is not entitled to any benefits under the policy.” 

AFCA also dismissed the claimant’s complaint that TAL had “unreasonably” delayed the claim assessment. 

The ombudsman says the claim was notified in January 2021, lodged in March and the final decision was made by early September that year – which is within the 12-month period for the insurer to be satisfied the policy terms have been met and the claim is accepted. 

Click here for the ruling.