Marcello Bertasso

Many insurance claims begin with a defining event. A diagnosis. A surgery. An accident. From there, there’s often a predictable path to recovery – a roadmap clients can follow with some certainty. Mental health claims often unfold very differently.

Conditions tend to develop gradually, sometimes over months or years, before a formal diagnosis is made. There’s rarely a single moment when a client moves from “well” to “unwell.” The terrain is often ambiguous, and each client’s journey is deeply individual.

Mental health has become one of the most discussed topics in life insurance – and for good reason. Billions of dollars are paid annually in mental health-related claims^[1] linked to psychological conditions, and the industry continues to see their growing role in protection portfolios.

Yet “mental health” encompasses a broad spectrum, from mood disorders and trauma-related conditions to behavioural disorders and neurodevelopmental conditions with complex comorbidities. Understanding this range provides valuable context for the experiences clients may face during a claim.

The winding road of mental health claims

If physical injury claims are like straight highways leading from diagnosis to recovery, mental health claims may resemble a winding mountain road.

Progress can be slow, unpredictable, and occasionally backtracking. Capacity can fluctuate week to week, and sometimes day to day. A client may show improvement for a period, then experience setbacks as treatment evolves or circumstances change.

Unlike a broken bone, psychological conditions cannot be seen on an X-ray or confirmed with a scan. Recovery is often assessed through a more nuanced lens: how someone manages the everyday demands of work and life.

This difference also influences claim duration.

Data from Safe Work Australia^[2] shows psychological injury claims generally involve longer periods away from work than many physical injuries. Reviews may happen in stages, with each new piece of evidence shaping the journey. Appreciating this rhythm helps explain why timelines aren’t linear and why each client’s journey can look very different.

For advisers, recognising this rhythm helps set realistic expectations for clients. Acknowledging that progress often comes in small, unexpected steps allows advisers to guide conversations empathetically, reassuring clients throughout the claims process.

How mental health claims are assessed

When assessing a mental health claim, the diagnosis is only one part of the story.

What insurers are really trying to understand is functional impact – how a client’s condition affects their ability to perform the specific duties of their role.

Think of it as the difference between knowing the weather forecast and seeing how it actually changes the commute. Diagnosis explains the condition; functional capacity explains what it means in practice.

Medical reports play a central role here. The level of detail can strongly influence how clearly a claim is assessed.

A note that a client is “not coping well” can be difficult to interpret. A report describing challenges with concentration, decision making, workload management, or client interaction provides a much clearer view of functional capacity.

Reports that link symptoms to specific tasks – handling a heavy workload, making high-stakes decisions, or engaging with clients – provide a far stronger basis for assessment than broad descriptions of distress. Insurers may also consider workplace adjustments or rehabilitation notes to build a fuller picture. The richer the detail, the easier it is for advisers to anticipate how a claim might evolve.

This is particularly important because mental health conditions often fluctuate.

Some clients respond quickly to treatment and support. Others experience periods of improvement followed by setbacks. Assessments are often conducted at multiple points in time to capture how capacity evolves.

For advisers, understanding this approach helps explain why timelines differ, and why patience is essential in supporting clients through mental health claims.

Why occupation matters more than many realise

One of the most interesting aspects of mental health claims is how strongly occupation shapes the claims journey.

Two clients can share the same diagnosis yet experience very different impacts depending on the nature of their work.

A portfolio manager making continuous investment decisions may face very different functional challenges compared with someone in a role with more structured or routine tasks.

Roles that involve sustained concentration, complex decision making, frequent client interaction, or long hours can place unique pressures on someone experiencing psychological strain.

That is why insurers assess not only the condition itself but also how it affects the duties of a client’s role.

For advisers, this perspective helps frame discussions with clients about what a claim might involve and which aspects of work may need support.

Questions such as:

• Which parts of your role currently feel most difficult to perform?
• Are there tasks that feel manageable and others that feel overwhelming?
• Has your doctor discussed what returning to work might look like for you?

help build a clearer understanding of how the condition affects day-to-day occupational demands and how advisers can support clients through the claim alongside the insurer.

Helping clients approach claims with confidence

For many clients, the claims process can feel unfamiliar and daunting. This is particularly true when mental health is involved, as the condition itself may already be affecting focus, confidence, or decision making.

In these moments, advisers play an important role in providing perspective.

Not by giving medical advice or directing the claims process, but by helping clients understand how claims are assessed and what the journey might involve.

When advisers understand the role of functional capacity, occupational demands, and the non-linear nature of recovery, they can frame conversations in ways that feel both informed and empathetic.

Even before a claim arises, this knowledge is valuable.

Mental health claims will likely continue to be an important part of the protection landscape. They are complex. Highly individual. And rarely predictable.

But when advisers understand how these claims are assessed, they are better positioned to guide conversations with clients early, helping them feel prepared, and reducing uncertainty.

Those early discussions can demystify the process, reduce uncertainty, and give clients a clearer sense of what to expect.

In many cases, that understanding alone can make the claims journey feel far less overwhelming.

And ultimately, that is what good advice aims to do: help clients navigate life’s uncertainties with greater confidence when it matters most.

By Marcello Bertasso, Head of Underwriting & Claims Management, PPS Mutual

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Notes:
[1] https://content.actuaries.asn.au/resources/resource-ce6yyqn64sx3-2093352434-60314?
[2] https://data.safeworkaustralia.gov.au/insights/key-whs-statistics-australia/latest-release

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Marcello Bertasso

Specialist insurance company PPS Mutual has announced significant changes to its mandatory screening evidence thresholds for the Professionals Choice insurance benefits, designed to streamline the application process for eligible professionals while maintaining high-quality underwriting standards.

PPS Mutual has reduced both mandatory medical and financial evidence requirements for new applications across its range of insurance products, including Professionals Choice Life, TPD, Trauma, Income Protection, and Business Expense insurance. These changes are aimed at simplifying and accelerating the new business process for prospective members without compromising the integrity of the underwriting assessment.

Marcello Bertasso, PPS Mutual’s Head of Underwriting and Claims Management, commented on the enhancements, noting that they would expedite the process of providing professional Australians with the peace of mind and wealth protection that PPS Mutual’s award-winning insurance offers.

“These changes simplify and accelerate the application process for life insurance with PPS Mutual, making it easier for advisers to protect our Members’ lifestyles,” he said. “For our Members, the updated screening requirements will significantly reduce the time needed to apply for life insurance.”

Changes include:

• higher sums insured limits before mandatory medicals and mandatory financials are required:
  • no mandatory PMAR up to $5 million Life and TPD insurance
  • no mandatory medical requirements for income protection cover increased to $15,000 monthly for ages up to 45, with fewer medical requirements for ages above 46
  • for income protection monthly benefits in excess of $40,000 per month, medical requirements reduced by half
  • no medical requirements for Life and TPD Insurance cover up to $2 million for ages up to 45, with fewer requirements for above age 46
  • no financial requirements for life and TPD cover up to $3 million or up to $1,5 million Trauma Insurance.
  • higher financial evidence thresholds for PAYG Employed professionals applying for Income Protection Select and Income Protection Prime 70 of up to $30,000 per month
  • defined medical requirements for higher life cover amounts ($5 million to $20 million)
  • simplified mandatory medical requirements across all age bands for all benefits, as well as simpler financial evidence for large sums insured.

PPS Mutual is supported by PPS South Africa, the largest multi-disciplinary group of professionals in the world and the largest mutual company in South Africa. PPS Mutual is based on the proven PPS business model that has been hugely successful in South Africa since the 1940s – sharing over $2.5 billion in profits with Members over the last 10 years. PPS Mutual is owned by its Australian professional members who will share in the profits of the products that they buy.

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PPS Mutual Members who hold in-force Income Protection benefits are now eligible to apply to add or increase Life, Total and Permanent Disability (TPD) or Trauma cover without requiring mandatory medical evidence.

The changes simplify the application process for existing Members who want to acquire Life, TPD or Trauma cover with PPS Mutual, effectively minimising their time burden.

Maximum benefit amounts

The offer enables Members to receive a maximum Life cover benefit of up to $3,000,000; TPD cover of up to $3,000,000; and Trauma cover (linked to Life or TPD) of up to $1,500,000 (or cover amounts equivalent to the amount that the medical evidence on record supports). Cover amounts in excess of these maximum benefit amounts would be subject to a full application and underwriting.

PPS Mutual’s Head of Underwriting and Claims Management Marcello Bertasso, describes the offer as “the latest advancement in PPS Mutual’s commitment to continually improve and innovate their Member experience.”

“Reducing the time and effort of providing mandatory medical evidence is part of our mission to remove ‘underwriting friction’ where possible and optimise our Members’ experiences.”

“This offer aligns with our mutual based value of putting our Members needs front and centre, whilst simultaneously maintaining a sustainable approach to our overall risk pool,” Mr Bertasso said.

Eligibility

Members with Income Protection (IP) benefits issued on or after 1 July 2019 (where loadings do not exceed +100% extra morbidity) will qualify.

This offer is available between 1 May 2021 and 30 June 2022, provided the applications for benefits is submitted and accepted during this period.

PPS Mutual products are offered exclusively through PPS Mutual accredited advisers.

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The changes have been designed to reduce the member application process by several weeks, minimising the time burden for Australia’s time poor professionals, while maintaining PPS Mutual’s commitment to responsible and sustainable underwriting by ensuring no additional risk has been added to the risk pool.

“As the only mutual insurer in Australia specifically for professionals, we have a strong understanding of the unique risk profile of this group and can be flexible and responsive to their specific needs. These recent changes form part of our ongoing commitment to continue to tailor our approach to serve the best interests of our members at all times,” said Marcello Bertasso, Head of Underwriting and Claims Management.

“Following an extensive study by PPS Mutual of all the quick check medicals, we found the rising costs of these assessments ultimately impacted the amount of profit returned to members,” he continued.

“Furthermore, a similar review of our underwriting book considering their financial risk profile found that no additional insights were added by the required questionnaires or third-party sign offs,” he said.

Key changes, applying to all existing and new policies, include the removal of the quick check medical requirement for prospective members aged 35 or under, who are requesting Income Protection up to a sum insured of $15,000 per month. The changes also remove the need for members of any age applying for Life Insurance of up to $20 million, Total and Permanent Disability insurance of up to $5 million, Trauma insurance of up to $2 million and Income Protection insurance of up to $30,000 per month, to undergo testing for Hepatitis B, Hepatitis C and HIV.

Additionally, when assessing a potential member’s financial situation, PPS Mutual has removed the need for those applying for Income Protection insurance to complete a full financial questionnaire and will now only request information that is relevant to the risk assessment. Third-party sign offs on financial questionnaires have also been removed for members wanting to insure for Income Protection.

By removing these requirements, PPS Mutual will lower operational costs to the business, and any resultant savings will ultimately flow to members via the unique Profit-Share arrangement.

“PPS Mutual’s products are designed to be tailored for the needs of professionals. Our decision to remove unnecessary underwriting elements won’t be the last change to our underwriting process,” Mr Bertasso said.

“We are guided by evidence-based principles, and will continue to seek feedback, analyse our processes and customise our underwriting methodology, to ease the process for our members, while maintaining a sustainable approach to our overall risk profile.”

PPS Mutual products are offered exclusively through PPS Mutual accredited financial advisers.

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Mr Salter will report directly to PPS Mutual Director of Distribution Brian Pillemer and will be responsible for the management of key financial adviser relationships and support of the PPS Mutual proposition within the regions. 

Mr Salter joins PPS Mutual after nine years in a business development role at Asteron Life, where he was responsible for achieving premium growth targets for Life Risk across a panel of financial advisers in Western Australia. 

“Steve is a valuable addition to the PPS Mutual team who brings extensive knowledge within the life insurance industry. This will be of great benefit in continuing to strengthen our partnerships with selected financial advisers in the region,” Mr Pillemer said.

With more than 25 years of experience in financial services, Mr Salter has a proven track record of consistently exceeding sales and growth targets in a business development role.

“I am excited to be a part of the PPS Mutual team – founded on principles of mutuality and exclusivity. PPS Mutual brings a unique offering to professionals in the Australian market and I look forward to explaining the benefits to advisers,” Mr Salter said. 

Mr Lowe, will report to Underwriting Manager, Gabi Varnier and joins PPS Mutual after five years as a senior underwriter at ANZ Wealth. David previously spent five years as a Private Wealth Protection Adviser and he will utilise this insight into adviser requirements by delivering bespoke underwriting support to PPS Mutual’s adviser partners.

“I look forward to welcoming David onto the team and expanding our reach. David’s extensive background as a senior underwriter is a testament to his strong capability of fostering both adviser and reinsurer relationships which will be pivotal to his role at PPS Mutual,” the Head of Claims and Underwriting, Marcello Bertasso said.

Earlier this year, PPS Mutual announced the launch of the PPS Mutual Super Fund, which allows the company to offer a complete life insurance solution for eligible professionals through a PPS Mutual accredited adviser.   

PPS Mutual is supported by PPS South Africa, the largest multi-disciplinary group of professionals in the world and the largest mutual company in South Africa.  PPS Mutual is based on the proven PPS business model that has been hugely successful in South Africa since the 1940s – sharing over $2.5 billion in profits with Members in the last 10 years.   

PPS Mutual is owned by its Australian professional members who will share in the profits of the products that they buy.  

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