Trauma claims require specialist medical evidence proving the diagnosis meets the specific PDS definition. Insurers do not accept a GP letter alone for Critical Illness Events; the evidence must come from the relevant specialist (oncologist, cardiologist, neurologist) and the supporting tests must be objective.
The evidence threshold is set by each insurer's PDS medical-definitions section. AIA states the proof must be a "study of the relevant and reasonably necessary histological material and clinical presentation" (AIA Priority Protection PDS (9 November 2025), Section 4).
What is required, by condition family
Different Critical Illness Events demand different evidence. Below are the standard categories.
Cancer claims
- Histopathology report confirming malignancy (tissue biopsy is the gold standard)
- Cancer staging report showing the TNM stage, Gleason score (prostate), Breslow depth (melanoma), or other staging where applicable
- Oncology specialist report confirming diagnosis and treatment plan
- For carcinoma in situ, specific evidence of grading (e.g. CIN 3 cervix per AIA Priority Protection PDS (9 November 2025), Section 4)
Heart attack claims
- Cardiologist report confirming myocardial infarction
- Elevated troponin levels above the threshold defined in the PDS Medical Definitions section
- ECG changes or imaging evidence of new wall motion abnormality
- TAL requires "confirmation of diagnosis by a Medical Practitioner and the specified severity threshold criteria to be met" (TAL Accelerated Protection PDS (12 December 2024), Section 2.3)
Stroke claims
- Neurologist report confirming stroke and permanent neurological deficit
- CT or MRI imaging showing the cerebrovascular event
- Evidence the deficit persisted beyond the time threshold in the PDS (commonly 24 hours of clinical deficit plus imaging confirmation)
- AIA requires "serious functional impairment", not just radiological evidence (AIA Priority Protection PDS (9 November 2025), Section 4)
Coronary Artery Bypass Surgery (CABG)
- Operative report detailing the surgery, vessels grafted, and approach
- Cardiologist or cardiothoracic surgeon report
- Hospital admission and discharge summaries
- AIA lists CABG as a full-payment Crisis Event (AIA Priority Protection PDS (9 November 2025), Section 4)
Other Critical Illness Events
- Specialist diagnostic report from the relevant medical discipline
- Imaging, pathology, or functional testing appropriate to the condition (e.g. nerve conduction studies for motor neurone disease, audiology for hearing loss, ophthalmology for blindness)
- Treating doctor clinical notes showing the condition history
What is universally required
Four pieces of evidence appear in every Trauma claim regardless of condition family.
- Authority to release medical information: signed by the claimant, allowing the insurer to obtain reports from any nominated doctor or hospital
- Claim form: completed by the claimant, with summary of diagnosis, date, and treating doctors
- Treating doctor statement: the GP or hospital's record of the diagnosis and history
- Specialist confirmation: the diagnosis must come from a Medical Practitioner with appropriate specialty (per AIA, the specialist must "act reasonably when determining their opinion" and base diagnosis on the PDS definition; AIA Priority Protection PDS (9 November 2025), Section 4)
Survival period evidence
Most panel policies require survival for 14 days from the date of the Critical Illness Event. The claim file therefore needs evidence of the date the event occurred and confirmation the claimant remained alive 14 days later. Cites:
- AIA Priority Protection PDS (9 November 2025), Section 4
- Zurich Wealth Protection PDS (1 November 2025)
- Encompass Protection PDS (26 September 2025)
Independent medical examinations
The insurer may commission an independent medical examination (IME) at their cost, particularly where the evidence is borderline or the diagnosis sits close to the PDS severity threshold. IMEs are a normal part of complex Trauma assessments and are not, of themselves, a sign the claim will be declined.
Privacy and consent
When you sign the medical authority, the insurer is entitled to obtain only the information reasonably required to assess the claim. The Privacy Act 1988 (Cth) and the Australian Privacy Principles (APP 6 and APP 11) govern how the insurer collects, uses, and stores the information. If you have concerns, ask the insurer to scope the authority to specific doctors and time periods rather than signing a blanket authority.
Tips that speed up the claim
- Provide all reports in one submission rather than dripping them through. Insurers can only start assessment once the file is reasonably complete.
- Pre-pay for specialist reports if they would otherwise take weeks to be released through Medicare channels.
- Use your adviser to co-ordinate the document gathering, particularly if you are still in active treatment.
This is general information, not personal advice. Specific evidence required will depend on the insurer, the condition, and the PDS in force at the time of claim.