When a CTP insurer changes an assessor mid-dispute, what does the Public Interest Committee (PIC) expect? Under NSW law, the PIC oversees claims under the Motor Accident Injuries Act 2017 (MAIA). If an insurer replaces a claims assessor or case manager during a dispute, the PIC expects the insurer to follow strict procedural rules to ensure fairness. This article explains the legal framework, practical steps for claimants, and time limits to challenge such changes.
The Legal Framework for Assessor Changes
NSW CTP insurers must comply with the MAIA and SIRA guidelines when managing claims. If an insurer replaces an assessor, it must provide a valid reason, such as a conflict of interest or lack of expertise. The PIC expects insurers to:
- Document the reason for the change in writing, including any internal review or medical opinion.
- Notify the claimant in writing within 14 days of the decision to change assessors.
- Provide access to the new assessor’s report and explain how it impacts the claim.
Under SIRA guidelines, insurers cannot unilaterally change assessors without just cause. If a claimant believes the change is unreasonable, they can request an internal review or escalate the matter to the PIC.
Practical Steps for Claimants
If your CTP insurer changes an assessor during a dispute, take these steps:
- Request a written explanation of why the change is happening. The insurer must provide specific reasons, such as a conflict of interest or a need for a specialist opinion.
- Ask for a copy of the new assessor’s report. The PIC requires insurers to share all relevant evidence with claimants.
- Seek clarification on how the change affects your claim. For example, does the new assessor’s opinion alter the estimated weekly payments or long-term benefits?
- Request an internal review if you believe the change is unfair. SIRA’s internal review process allows claimants to challenge decisions without leaving the CTP scheme.
- Consider external review if the insurer refuses to resolve the issue. The PIC may refer the matter to the Personal Injury Commission (PIC) for further investigation.
Time Limits and Dispute Resolution
NSW CTP insurers must act within strict timeframes. If an insurer changes an assessor without proper justification, claimants have 28 days to request an internal review. If the insurer fails to respond or resolve the issue, the claimant can escalate the matter to the PIC.
The PIC has the authority to:
- Order the insurer to revert to the original assessor if the change is deemed unreasonable.
- Review the claim independently if there is a dispute over the assessor’s findings.
- Issue a formal notice to the insurer if it fails to comply with procedural rules.
Claimants should note that the PIC does not automatically overturn decisions. The insurer must demonstrate that the change was necessary and in the public interest.
A Hypothetical Example
Imagine a claimant who sustained a soft-tissue injury in a car accident. The initial assessor estimated 52 weeks of weekly payments. The insurer later replaces the assessor, claiming the original report was incomplete. The claimant requests a written explanation and discovers the new assessor’s report reduces the payment period to 36 weeks. Under SIRA guidelines, the insurer must justify this change. If the claimant believes the new assessor’s opinion is biased or based on incomplete evidence, they can request an internal review to challenge the decision.
When to Seek Legal Advice
If the insurer refuses to provide a written explanation, delays the review process, or fails to comply with SIRA guidelines, claimants should seek legal advice. A solicitor can help:
- Challenge the insurer’s decision through the PIC’s internal review process.
- Escalate the matter to the NSW Civil and Administrative Tribunal (NCAT) if the insurer refuses to comply.
- Negotiate a fair settlement if the dispute is unresolved.
Next Steps
CTP insurers must follow strict rules when changing assessors. If you believe the change is unfair, act quickly to request an internal review. The PIC expects insurers to provide clear reasoning and evidence for any changes. For personalized guidance, complete the quick, no obligation enquiry form to discuss your circumstances.
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