A vehicle mechanic has won a total and permanent disability claim dispute after the ombudsman ruled his insurer assessed his case “without fairly considering” his prospects of finding suitable work.

The mechanic held a TPD policy with Zurich through his super fund and lodged a claim in May 2016 over injuries and a stress disorder caused by a motor accident on October 4 2006.

Zurich denied the claim in December 2016, but the mechanic’s super trustee asked it to reconsider. The insurer again denied the claim on March 28 2017.

The Australian Financial Complaints Authority says Zurich should have reassessed the claim with “fresh eyes” after the trustee challenged its first decision.

Medical evidence provided to AFCA shows the mechanic, who has not worked since the accident, has physical restrictions that mean he is unlikely to again do work that “reasonably” matches his education, training or experience.

Zurich’s policy requires an insured to be permanently incapacitated to such an extent they are unlikely to engage in gainful occupation, business, profession or employment that suits their education, training or experience.

They must meet these criteria for six consecutive months.

AFCA says the evidence shows the complainant has functional restrictions. Injuries to his left knee and foot mean he cannot kneel or crawl, has difficulty balancing on uneven surfaces, cannot bear weight through his left leg and can only climb stairs or ladders occasionally.

It says the complainant met the policy’s TPD definition on April 4 2007 – six months after his accident.

“Based on his physical restrictions alone, the insurer should have found that, as at April 4 2007, the complainant was unlikely to ever be able to engage in any occupation for which he was reasonably suited by his [education, training or experience],” an AFCA ombudsman said.

“In my view, the trustee’s challenge was an opportunity for the insurer to take a longitudinal view and to reconsider the claim with fresh eyes. Its response to the trustee indicated it did not do so, but was fixed on the evidence ‘around the date of assessment’.”

AFCA has ordered the insurer to accept the complainant’s claim. Click here for the ruling.