Dispute resolution for care and family support in NSW CTP claims
If you or a family member have suffered a serious injury in a motor accident in New South Wales and are seeking compensation for care and family support needs, you may encounter disagreements with your insurer about the level or type of support you are entitled to. Disputes over care and family support claims are resolved through structured pathways under the Motor Accident Injuries Act 2017 (MAIA), administered by the State Insurance Regulatory Authority (SIRA). In Greater Sydney, claimants can access formal dispute resolution options including internal review, mediation and, if necessary, a hearing before the Personal Injury Commission (PIC).
Legal framework for care and family support entitlements
Under the MAIA, a person who has suffered a serious injury in a motor accident may be entitled to claim for care and family support services. These benefits cover both paid care (such as home care assistance) and unpaid care provided by family members. The entitlement is not automatic and depends on a documented need for assistance with daily personal care tasks such as bathing, dressing, eating, or managing medication.
To qualify, the injury must have resulted in a permanent or long-term need for care. The claim must be supported by a medical report from a qualified practitioner, including a description of the functional limitations and the type and frequency of care required. The need for care must be directly attributable to injuries sustained in the motor accident.
Available dispute resolution pathways
If your insurer denies or limits your claim for care and family support, you have several formal options to resolve the dispute. The first step is to request an internal review of the decision from your insurer. Insurers are required to provide a written response within 28 days of your request. This internal review is a mandatory step before progressing to external dispute resolution.
If the internal review does not resolve the dispute, you may apply to SIRA for mediation. Mediation is a voluntary process where a neutral SIRA officer helps both parties reach a settlement. It is often quicker and less adversarial than formal hearings. Mediation is available for disputes involving care and family support, and SIRA will assist in arranging a session, particularly for claimants in Greater Sydney who may face logistical challenges.
If mediation is not successful, you may apply to the Personal Injury Commission for a formal hearing. The PIC has jurisdiction to review decisions on care and family support entitlements, including the level of care, the type of support (paid or unpaid), and the duration of the benefit. The PIC will consider all evidence, including medical reports, care logs, and witness statements, before making a binding determination.
Practical steps and evidence that matter
To strengthen your claim and improve the chances of a favourable outcome in dispute resolution, gather and preserve the following evidence:
- A detailed medical report from your treating medical practitioner, confirming the need for care and specifying the nature and frequency of required assistance.
- A care plan or care log documenting the actual time spent by family members on care tasks, including dates, times, and activities performed.
- Photographs or videos showing the impact of the injury on daily living, such as difficulty using stairs, transferring from a bed, or preparing meals.
- Correspondence with your insurer, including written requests for review and responses received.
- A statement from a family member detailing the hours spent providing unpaid care and the impact on their own work or wellbeing.
A realistic example: A 42-year-old mother in Sydney’s Inner West sustained a spinal injury in a car accident. She requires daily assistance with personal care and household tasks. Her husband, who previously worked full time, now provides 30 hours of unpaid care per week. The insurer initially refused to recognise the full extent of the unpaid care claim. After submitting a care log, medical evidence, and a statement from the husband, the matter was referred to SIRA mediation. The mediator helped reach a settlement that included recognition of the unpaid care hours and a weekly payment for paid care services.
Time limits and procedural requirements
There is no fixed deadline for initiating a dispute resolution process under the MAIA, but delays may affect the availability of evidence or the accuracy of care logs. It is advisable to begin the process as soon as a dispute arises. The internal review must be requested within 12 months of receiving the insurer’s decision. If you miss this window, you may still apply to the PIC, but the delay could impact the outcome.
The PIC will not automatically overturn a decision. It will assess whether the insurer’s decision was reasonable based on the evidence. A challenge does not guarantee a change in the outcome. The PIC may uphold the insurer’s position, order a review, or direct a new assessment.
When to seek independent advice
Disputes over care and family support can be complex, particularly when unpaid care is involved or when the insurer disputes the medical evidence. Given the long-term financial and personal impact of a denied claim, it is advisable to seek independent legal advice before initiating any formal dispute process. A solicitor experienced in motor accident claims can help you assess the strength of your evidence, prepare a submission, and represent you at mediation or a PIC hearing.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.