The Insurance Claims Process — How It Works

Most people have never made an insurance claim before. The process is unfamiliar, the stakes are high, and it arrives at one of the worst moments of your life. This page explains what actually happens — and where GCFA fits in.

Before You Lodge — The Step Most People Skip

The most common mistake people make with insurance claims is lodging before they understand what they need to prove. An insurance claim is not simply notifying your insurer that something has happened. It is a formal process in which you must demonstrate — with evidence — that the specific conditions in your policy have been met.

Before anything is submitted, GCFA reviews your policy wording in detail. We identify exactly which definition applies to your claim, what evidence the insurer will require to assess it, and whether there are any exclusions or conditions that need to be addressed upfront. This preparation step is what separates a well-run claim from one that spends months going back and forth.

Stage 1 — Discovery

We start by building a complete picture of your situation. This means reviewing your policy document — not just the summary, but the full wording including definitions, exclusions and conditions. We look at your medical situation, your employment history, and any prior dealings with the insurer that may be relevant.

Where cover is held inside superannuation, we also review the trust deed and group insurance certificate, as these govern the claim alongside the policy wording. Many claimants don’t realise that super fund TPD claims involve both the insurer and the trustee — two separate assessment processes running in parallel.

Stage 2 — Strategy

Once we understand the policy and the situation, we map the claim pathway. This means identifying precisely what definition must be satisfied, what evidence is needed to satisfy it, who needs to provide that evidence, and what the realistic timeline looks like.

For medical evidence, this is more specific than most people expect. A treating doctor’s letter confirming a diagnosis is rarely sufficient on its own. The insurer needs evidence that addresses their specific definition — for example, a TPD claim under an “any occupation” definition requires evidence that speaks to your capacity to work in any occupation, not just your current one. A trauma claim for stroke requires evidence of permanent neurological deficit, not just confirmation of the stroke event itself.

We brief your treating specialists on exactly what the policy requires so their reports address the right questions. This single step eliminates the most common cause of claim delays.

Stage 3 — Lodgement

We compile all documentation — medical reports, financial records, claim forms, employer statements and any other required evidence — and submit the claim to the insurer on your behalf. We manage all correspondence from this point forward.

You will not be fielding calls from the insurer, filling out forms under pressure, or wondering what to say. Every communication goes through us. This matters more than it might seem — what you say to an insurer during the claims process can affect the outcome, and having an adviser manage that communication is a practical safeguard.

Stage 4 — Assessment and Follow-Up

Once lodged, the insurer assesses the claim against their internal processes. We track progress, respond to requests for additional information, and follow up proactively when timeframes are being exceeded. If the insurer requests an independent medical examination (IME), we help you prepare for that process.

Not every insurer communicates well during assessment. Some are slow. Some issue repeated requests for information that was already provided. Some request IMEs as a matter of course rather than genuine necessity. We know the patterns and we push back where appropriate — professionally and effectively.

Stage 5 — Resolution

The insurer issues a decision — either approving the claim, partially approving it, or declining it. If the claim is approved, we confirm the payment terms and ensure the benefit is paid correctly and on time.

If the claim is declined or only partially approved, the process doesn’t end there. We review the decision, assess whether there are grounds to challenge it, and advise you on the options available — internal review, AFCA complaint, or in complex cases, legal advice. A declined claim is not automatically the final word. See our Declined Claims page for more detail on this process.

What If I’ve Already Started a Claim?

We can help at any stage — not just from the beginning. If you’ve already lodged a claim and it’s stalled, you’ve had a decision you’re not happy with, or you’re simply not sure what’s happening, contact us. We’ll review where things stand and give you an honest picture of your options. There’s no point at which getting professional support stops being worthwhile.

Frequently Asked Questions