Not every review identifies meaningful weaknesses. Sometimes the insurer’s position is well supported. The purpose of this review is to determine whether the reasoning holds together, not to manufacture arguments.
This is a real example of how a declined TPD claim is analysed, where the insurer’s reasoning is examined, and how pressure points and challenge leverage are identified before you respond to the decision.
Prepared for: REDACTED REFERENCE SAMPLE
File Reference: N/A
Date of Delivery: November 14, 2004
Insurer: Perfect Life Insurance Limited
Date of Declinature: November 14, 2004
Claimant: Tom Sample
This is a redacted sample. Names, policy details, insurer, and dates have been modified to protect confidentiality.
This sample review was prepared for an advisor in Australia. I also prepare reviews for advisers in New Zealand and Canada. Dispute authority references are tailored to the jurisdiction of each submitted file.
This review reflects independent analytical review of the submitted documents only. It does not constitute legal advice, financial advice, or expert testimony. The findings should be evaluated by the adviser in the context of their professional relationship with their client and, where recommended, in conjunction with a specialist TPD lawyer.
This review examines the submitted declinature and supporting documents in detail so that the findings can be acted on directly, and whether that means writing to the insurer, lodging an AFCA complaint, or briefing a specialist TPD lawyer if that is what the analysis recommends.
You do not need to read this in full before taking action. Here is where to start:
If you want to know what to do right now: start with the Decision Support Summary.
If you want to understand the key weaknesses in the declinature: read the Executive Assessment. It identifies the highest-leverage vulnerabilities in two to three minutes.
If you are writing to the insurer: the Draft IDR Letter at the end of the report is ready to review, edit, and send on your letterhead. It is built directly from the findings in this review.
If you are briefing a lawyer: the full review provides everything they need. The Clarification Questions in Section 2 are the most directly useful sections for that briefing.
The insurer declined the claim under the Any Occupation definition. It based the denial on the absence of medical records establishing functional decline between mid-2003 and work cessation in January 2004. The declinature applies the stricter definition without establishing the threshold requirement in clause 7.2(iii): that Mr Sample ceased work for reasons other than his hip injury.
The insurer identified a gap in the clinical records and treated that gap as though it were evidence of non-medical work cessation. The policy wording does not permit that substitution. The Own Occupation definition should apply unless the insurer can identify what non-medical reason caused him to stop working.
Key Findings
The insurer relied on Dr Boucher’s September 2004 examination to assess functional capacity at the time Mr Sample ceased work in January 2004. Dr Boucher examined him eight months after work cessation. Dr Kinko’s June 2004 report provides the only clinical assessment within six months of work cessation. It documents progressive decline in hip range of motion, new onset low back pain worsening over eighteen months, abductor weakness, and persistent antalgic gait.
The declinature does not explain why a delayed assessment showing improvement should override findings from the period surrounding work cessation.
The declinature states that by mid-2003 Dr Kinko documented normal gait and painless hip motion, then uses this to support the conclusion that no functional decline occurred before work cessation. Dr Kinko’s June 2004 report documents ongoing chronic pain rated 3-4/10 baseline and 5-6/10 with activity, decreased hip range of motion in all planes compared to 2003, abductor weakness, and compensatory low back pain. The insurer selectively quoted from mid-2003 progress notes and ignored the June 2004 report that directly addresses functional capacity and disability status.
Dr Boucher identified symptom magnification findings. The insurer used this to question the reliability of Mr Sample’s pain reporting. Dr Kinko addressed pain credibility specifically in his June 2004 report, stating that the pain is consistent with documented structural findings and is not disproportionate to objective findings. He identified structural correlates including hardware irritation, neuropathic nerve involvement, progressive impaction deformity, and leg length discrepancy causing compensatory pain.
The declinature does not explain why a single examination should override the longitudinal treating surgeon’s assessment on pain credibility.
Dr Boucher assessed sedentary capacity as defined in the Dictionary of Occupational Titles. The insurer then concluded this capacity is consistent with administrative management, supervisory roles, consultancy, and office-based functions. Dr Boucher did not assess capacity for those specific occupations. The insurer has not established that sedentary DOT capacity corresponds to the occupations for which Mr Sample is reasonably qualified by his actual work history in museum administration.
Clause 7.3 permits reliance on functional capacity but does not permit substitution of a generic DOT category for the occupations he is qualified to perform.
The insurer acknowledged that Dr Kinko stated Mr Sample is not at maximum medical improvement and documented ongoing treatment adjustment. It then assessed functional capacity using Dr Boucher’s September 2004 findings as though his condition were static. Clause 7.5 permits assessment of residual functional capacity once maximum medical improvement has been reached. The insurer has not explained how it resolved the conflict between Dr Boucher’s opinion that MMI was reached and Dr Kinko’s opinion that it was not.
Primary Concession Targets
The insurer has not identified what non-medical reason caused Mr Sample to cease work in January 2004 as required by clause 7.2(iii) before applying the Any Occupation definition.
The insurer has not explained why Dr Boucher’s September 2004 examination, conducted eight months after work cessation, should override Dr Kinko’s June 2004 documentation of functional decline during the relevant period.
The insurer has not identified which specific occupation within the sedentary administrative category Mr Sample is qualified to perform by his actual work history and experience.
The insurer has not reconciled Dr Kinko’s June 2004 finding that Mr Sample is not at maximum medical improvement with its assessment of functional capacity as fixed and permanent.
The insurer has not addressed Dr Kinko’s documented clinical rationale for the reported pain or explained why symptom magnification findings override structural correlates documented on examination and imaging.
The insurer has not obtained any vocational assessment to establish that the identified occupations are realistically available and sustainable given the documented pain profile and functional restrictions.
The insurer applied the Any Occupation definition without establishing that clause 7.2(iii) was satisfied
The declinature applies the Any Occupation definition on the basis that “the medical records document a period of functional recovery prior to your cessation of work in January 2004” and that the records “do not provide a clear clinical explanation for a material decline in functional capacity between mid-2003 and January 2004.”
Clause 7.2(iii) requires the insurer to establish that the member ceased work for reasons “other than or in addition to” the illness or injury giving rise to the claim. The insurer has not identified what those other reasons were. The declinature states that it cannot see a clinical explanation for work cessation in the medical records. That is not the same as establishing that Mr Sample ceased work for non-medical reasons.
The Own Occupation definition should apply unless the insurer can point to a specific non-medical reason for work cessation. The declinature identifies a reasoning gap and then treats that gap as if it were evidence of non-medical cessation. The policy wording does not support that interpretation.
Dr Boucher assessed functional capacity eight months after work cessation, not at the time Mr Sample stopped working
The insurer relies on Dr Boucher’s September 2004 examination to determine that Mr Sample had sedentary work capacity at the time he ceased work in January 2004. Dr Boucher examined him eight months later.
Dr Kinko’s June 2004 report provides the only clinical assessment within six months of work cessation. It documents progressive decline in hip range of motion compared to 2003, new onset low back pain worsening over eighteen months, abductor weakness, persistent antalgic gait, and leg length discrepancy inadequately compensated by the prescribed lift. Dr Kinko explicitly states that Mr Sample is not at maximum medical improvement.
The insurer has used a later examination showing improvement to infer backwards what capacity must have been at work cessation. Dr Kinko’s contemporaneous findings do not support that inference. The declinature does not explain why a delayed assessment should be preferred over findings from the period surrounding work cessation.
The declinature recharacterises Dr Kinko’s clinical findings as though they document full recovery
The insurer states that by mid-2003 Dr Kinko documented “essentially normal gait with painless hip motion” and that by mid-June 2003 the fracture had healed and Mr Sample was “released from Dr Kinko’s direct care.”
Dr Kinko’s June 2004 report provides the most detailed functional assessment on file. It documents ongoing chronic pain rated 3-4/10 baseline and 5-6/10 with activity, decreased hip range of motion in all planes compared to 2003, abductor weakness, persistent antalgic gait, neuropathic thigh pain requiring Neurontin, compensatory low back pain, and leg length discrepancy causing functional limitation. Dr Kinko states that the pain is “consistent with documented structural findings and is not disproportionate to objective findings.”
The insurer has selectively quoted from mid-2003 progress notes and ignored the June 2004 report that directly addresses functional capacity and disability status. Dr Kinko did not document full recovery or capacity to return to work. He documented ongoing structural impairment, chronic pain with documented objective correlates, and functional limitations requiring continuing treatment adjustment.
The insurer relied on symptom magnification findings to question the reliability of Mr Sample’s pain reporting but did not address Dr Kinko’s assessment of pain credibility
Dr Boucher identified “findings suggestive of symptom magnification on pain drawing assessment” and used this to question the reliability of subjective complaints. The insurer adopted this interpretation and used it to support the conclusion that the claim is not well-founded.
Dr Kinko addressed this issue specifically in his June 2004 report. He stated that Mr Sample’s pain is “consistent with documented structural findings and is not disproportionate to objective findings.” Dr Kinko identified structural correlates for the reported pain: hardware irritation, neuropathic nerve involvement from the surgical approach, progressive impaction deformity, abductor weakness, and leg length discrepancy causing compensatory lumbar and SI joint pain.
The insurer accepted Dr Boucher’s interpretation but did not acknowledge or address Dr Kinko’s contrary clinical opinion. Dr Kinko has treated Mr Sample for three years and has access to the longitudinal clinical course. The declinature does not explain why a single examination should be preferred over a longitudinal assessment on the specific question of pain credibility.
Dr Boucher assessed sedentary capacity but the policy requires assessment against occupations for which Mr Sample is reasonably qualified
Dr Boucher concluded that Mr Sample has “at least a sedentary work capacity as defined in the Dictionary of Occupational Titles” with capacity to lift 10 pounds occasionally, sit and stand for reasonable periods with position changes, and walk for 15 minutes per hour.
The insurer then concluded that this functional capacity is “consistent with performance of a range of occupations for which you are reasonably qualified by your education, training, and experience” including “administrative management, supervisory and coordinative roles, consultancy, and office-based functions.”
Dr Boucher did not assess capacity for those specific occupations. He assessed capacity for the DOT sedentary category, which includes a wide range of roles that do not match Mr Sample’s work history. Museum administration involves physical oversight of a facility, coordination of public-facing operations, and staff management requiring mobility and physical presence.
The insurer has not established that sedentary capacity as defined in the DOT corresponds to the occupations for which Mr Sample is reasonably qualified by his actual work experience. Clause 7.3 permits the insurer to rely on functional capacity when assessing any occupation, but it does not permit substitution of a generic DOT category for the occupations Mr Sample is actually qualified to perform.
The insurer stated that Mr Sample is not at maximum medical improvement in one part of the declinature and then assessed capacity as though he were stable
The insurer acknowledged that Dr Kinko’s June 2004 report states Mr Sample is not at maximum medical improvement. Dr Kinko documented ongoing treatment adjustment including an increased heel lift prescription, a new behavioral health referral for depression, and continuing medication management. He stated that “further treatment trials remain available and have not been exhausted.”
The insurer then assessed functional capacity using Dr Boucher’s September 2004 findings as though his condition were static. Clause 7.5 permits assessment of residual functional capacity once maximum medical improvement has been reached. It does not permit the insurer to assess residual capacity before that point and treat it as permanent.
Dr Boucher stated that Mr Sample had reached maximum medical improvement. Dr Kinko stated that he had not. The insurer has not explained how it resolved that conflict or why it proceeded to assess permanent capacity when the treating surgeon documented an unstable clinical picture with ongoing treatment adjustments.
The declinature criticised the appropriateness of Mr Sample’s medication but did not establish that this affects the claim assessment
The insurer quoted Dr Boucher’s opinion that the use of Avinza is “inappropriate given the absence of objective clinical findings consistent with the level of pain described” and that Neurontin is “inappropriate given the absence of evidence of neuropathic pain.” The insurer then stated that “these findings inform our assessment of the overall clinical picture and the reliability of subjective complaints underpinning the claim.”
Dr Kinko prescribed both medications and documented the clinical rationale in detail. He identified structural findings supporting the pain complaints: hardware irritation, progressive impaction deformity, neuropathic involvement of the lateral femoral cutaneous nerve from the surgical approach, abductor weakness, and compensatory lumbar facet arthrosis. He stated that Avinza was initiated after failed trials of non-opioid treatment and that Neurontin produced a documented 40 percent reduction in neuropathic pain.
The insurer has used a disagreement about prescribing appropriateness to question the legitimacy of the underlying pain complaints. That reasoning conflates two separate issues: whether the medications are the best clinical choice and whether the pain they are prescribed to treat is real.
Dr Kinko documented objective findings supporting the pain. The declinature does not explain how a difference of opinion about medication choice affects whether Mr Sample meets the TPD definition.
Clarification Questions
Record and Documentation Gaps
The declinature references clinical records from One Medical Center and The Medical Center but does not identify which specific records were reviewed or the date range covered. Dr Boucher’s report states that no records prior to 18 December 2001 or subsequent to 14 June 2004 were available to him at the time of his examination. The declinature does not clarify whether additional records were subsequently obtained or reviewed by the insurer’s claims team.
No vocational assessment, functional capacity evaluation, or workplace ergonomic assessment has been provided or referenced. The insurer has concluded that Mr Sample retains capacity for a class of sedentary and administrative occupations without documented vocational analysis of whether those occupations are realistically available, sustainable, or compatible with the documented pain and medication profile.
No psychiatric or psychological assessment has been obtained despite Dr Kinko documenting mild depression (PHQ-9 score of 7) and providing a behavioural health referral in June 2004. Dr Boucher administered the CES-D depression screening in September 2004, which produced a score of 10. The declinature does not address whether any assessment of psychological or psychiatric contribution to functional limitation has been undertaken.
The insurer has reserved rights under clause 7.4 regarding pre-existing conditions but has not obtained any opinion on the extent to which the pre-existing hip fracture contributes to current disability as distinct from subsequent progression or complication. Clause 7.4 requires assessment of “the extent of contribution” where a pre-existing condition contributes but is not solely responsible for disablement. No such assessment is evident in the submitted materials.
Recommend the adviser request internal dispute resolution and refer the matter to a specialist TPD lawyer in parallel. The declinature reasoning is vulnerable on policy construction, medical evidence interpretation, and internal consistency. An internal review should address these issues, but they may also require formal challenge.
The declinature depends entirely on the proposition that Mr Sample had functional capacity at January 2004 consistent with sedentary work, and that Dr Boucher’s September 2004 examination provides reliable evidence of what that capacity was eight months earlier. Neither proposition withstands direct examination against the submitted medical record.
Dr Boucher examined Mr Sample in September 2004 and documented findings at that point in time. The insurer has extrapolated backwards from those findings to conclude that Mr Sample possessed sedentary work capacity in January 2004 when he ceased work.
Dr Kinko’s June 2004 record directly contradicts this. This is the only treating physician assessment within proximity to the work cessation date. Dr Kinko documented declining hip range of motion compared to the prior year, persistent pain on resisted abduction, abductor weakness demonstrated by positive Trendelenburg sign, ongoing antalgic gait, and a 2.8 cm leg length discrepancy producing compensatory low back pain. He stated that Mr Sample was not at maximum medical improvement and that functional capacity remained limited by chronic pain, leg length discrepancy, and abductor weakness.
The insurer has not addressed this assessment. It has simply relied on Dr Boucher’s later examination and treated the intervening treating physician findings as if they do not exist.
The insurer applied the Any Occupation definition on the basis that the evidence does not clearly establish functional incapacity at the date of work cessation. The policy wording in clause 7.2 does not support this application. Clause 7.2 requires the Own Occupation definition to apply where the member was in active employment immediately prior to disablement and ceased work solely as a result of the illness or injury. The insurer has reserved the right to apply the Any Occupation definition where work cessation occurred for reasons other than or in addition to the condition, but it has not established that this occurred here.
The declinature letter refers to a period of functional recovery and states that the records do not provide a clear clinical explanation for material decline between mid-2003 and January 2004. This is not a positive finding that Mr Sample ceased work for reasons unrelated to his hip condition. It is an assertion that the insurer cannot identify a clinical explanation in the records.
Dr Kinko’s June 2004 assessment provides that explanation: progressive impaction deformity, declining range of motion, persistent pain, gait abnormality, and compensatory low back pain.
The insurer’s inability to reconcile Dr Boucher’s findings with Dr Kinko’s findings is not the same as establishing that the Own Occupation definition does not apply.
The functional capacity opinion in Dr Boucher’s report is qualified by his own findings. He documented symptom magnification on pain drawing, noted that his sitting and standing capacity estimates were assumptions rather than observations, and stated that Mr Sample should avoid driving or operating machinery due to multiple sedating medications. The insurer has adopted the sedentary work capacity conclusion without addressing these qualifications or explaining how sedentary work capacity can be reconciled with avoidance of driving and machinery operation. This matters particularly for someone whose work history involves museum administration and whose reasonable alternative occupations would likely involve travel, meetings, and operational coordination.
30 May 2026
Internal Dispute Resolution Team
Perfect Life Insurance Limited
Claims Assessment Division
PO Box [redacted for this sample]
Sydney NSW 2001
Re: Internal Dispute Resolution Request — Tom Sample — Policy No. GL-2004-447 — Claim No. TPD-2004-0892
Dear Sir or Madam,
I am a licensed financial adviser acting on behalf of Mr Tom Sample in relation to his Total and Permanent Disablement claim under Policy No. GL-2004-447. I have reviewed the declinature letter dated 14 November 2004 and formally dispute that decision. This letter constitutes a request for internal review under your dispute resolution process.
Background
Mr Sample sustained a left hip fracture on 18 December 2001 whilst employed as a museum administrator with The Fort at #4. He continued working with medical treatment and physical accommodations until ceasing on 12 January 2004 due to ongoing hip pain, functional limitation, and associated low back pain. He lodged his TPD claim on 18 August 2004.
The insurer declined the claim on 14 November 2004 applying the Any Occupation definition under clause 7.1(b). The declinature concluded that Mr Sample retains sedentary work capacity sufficient to perform administrative and office-based occupations for which he is reasonably qualified.
Grounds for Dispute
Clause 7.2(iii) requires that the Own Occupation definition apply unless the member “ceased work for reasons other than or in addition to the illness or injury giving rise to the claim.” The declinature states that the medical records “do not provide a clear clinical explanation for a material decline in functional capacity between mid-2003 and January 2004.”
The absence of a clear clinical explanation in the insurer’s view does not establish that Mr Sample ceased work for non-medical reasons. The declinature does not identify what those other reasons were.
The Own Occupation definition should apply unless the insurer can point to a specific non-medical reason for work cessation.
Dr Boucher examined Mr Sample eight months after he ceased work. The insurer used his findings to determine functional capacity “at and around the date of work cessation” without explaining how a delayed examination establishes capacity eight months earlier.
Dr Kinko’s June 2004 report provides the only clinical assessment within six months of work cessation. It documents progressive decline in hip range of motion compared to 2003, new onset low back pain worsening over eighteen months, abductor weakness, persistent antalgic gait, and leg length discrepancy inadequately compensated by the prescribed lift.
The insurer inferred backwards from a later examination showing improvement without addressing the contemporaneous findings of functional decline.
The insurer states that by mid-2003 Dr Kinko documented “essentially normal gait with painless hip motion” and that the fracture had healed with Mr Sample released from direct care. Dr Kinko’s June 2004 report directly contradicts this characterisation.
It documents ongoing chronic pain rated 3-4/10 baseline and 5-6/10 with activity, decreased hip range of motion in all planes compared to 2003, abductor weakness, persistent antalgic gait, neuropathic thigh pain requiring Neurontin, compensatory low back pain, and leg length discrepancy causing functional limitation. Dr Kinko states that the pain is “consistent with documented structural findings and is not disproportionate to objective findings.”
The insurer selectively quoted from mid-2003 progress notes and ignored the June 2004 report that directly addresses functional capacity and disability status.
The insurer acknowledged that Dr Kinko’s June 2004 report states Mr Sample is not at maximum medical improvement and that “further treatment trials remain available and have not been exhausted.” It then assessed functional capacity using Dr Boucher’s September 2004 findings as though his condition were static.
Clause 7.5 permits assessment of residual functional capacity once maximum medical improvement has been reached. Dr Boucher stated that Mr Sample had reached maximum medical improvement. Dr Kinko stated that he had not.
The insurer has not explained how it resolved that conflict or why it proceeded to assess permanent capacity when the treating surgeon documented an unstable clinical picture with ongoing treatment adjustments.
Dr Boucher concluded that Mr Sample has sedentary work capacity as defined in the Dictionary of Occupational Titles including the ability to sit and stand for reasonable periods with position changes and walk for fifteen minutes per hour. The insurer then concluded that this capacity is “consistent with performance of a range of occupations” including “administrative management, supervisory and coordinative roles, consultancy, and office-based functions.”
The insurer has not identified what specific occupation within those categories Mr Sample is qualified to perform by his actual work history as a museum administrator. Museum administration involves physical oversight of a facility, coordination of public-facing operations, and staff management requiring mobility and physical presence.
Clause 7.3 permits reliance on functional capacity when assessing any occupation, but not substitution of a generic functional category for the occupations Mr Sample is actually qualified to perform.
Questions Requiring Response
As part of the internal review I request written responses to the following:
Requested Outcome
I request that the insurer formally reconsider the declinature of 14 November 2004 and provide a written response addressing each ground and each question raised in this letter within 21 days of receipt. My client and I reserve all rights pending the outcome of this internal review.
Thank you for your attention to this matter. Please direct all correspondence to me at the details below.
Yours faithfully,
[Adviser name]
[Adviser firm]
[Contact details]
Enclosures:
This review identifies where the insurer’s position is weakest and what that means for your client’s claim before you make a call either way.
The first review for any new firm is complimentary.
Send the disputed claim you are least sure about.