The Role of Claims Assessors in NSW CTP Claims
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
A claims assessor is a person appointed under the Motor Accident Injuries Act 2017 to review and make decisions about motor accident compensation claims in New South Wales. Their role is to assess whether an insurer’s decision to deny, limit or otherwise manage a claim is consistent with the law and the Motor Accident Injuries Regulations 2017. This includes evaluating whether entitlements to treatment and care benefits, weekly income payments or damages are properly applied.
In regional NSW, claims assessors are often engaged when a claimant disputes an insurer’s decision, particularly where medical evidence, injury classification or financial loss is contested. The assessor does not determine fault but reviews whether the insurer’s application of the law, including SIRA’s Motor Accident Guidelines, is correct. Their decision may be binding on the insurer, especially where a claimant has not commenced legal proceedings.
How Claims Assessors Review Insurer Decisions
Claims assessors base their review on the Motor Accident Injuries Act 2017 and the SIRA-issued Motor Accident Guidelines. These documents set out the legal standards for determining eligibility for benefits and damages. For example, if an insurer denies weekly income payments because the injury is considered a threshold injury, the assessor will determine whether the injury meets the legal definition under the Act.
The assessor examines all available evidence, including medical reports, treatment records, employment documentation and accident details. They assess whether the insurer has correctly applied the 52-week rule for threshold injuries, which limits statutory benefits after 52 weeks if the only injuries are threshold injuries. The assessor also checks whether the insurer has properly considered the whole person impairment (WPI) rating and whether the claimant has met the threshold for damages under section 4.4 of the Act.
In regional areas, assessors may also consider practical factors such as access to specialist medical care, travel time to treatment, and the availability of local rehabilitation services. These factors can influence whether a claimant’s needs are being met under the insurer’s management of treatment and care benefits.
Practical Steps to Understand Insurer Decisions
To understand an insurer’s decision, a claimant should first obtain a written explanation from the insurer. This may be in the form of a decision letter, a letter of refusal, or a notice of variation to benefits. The letter should set out the legal basis for the decision, including reference to the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines.
Next, gather all relevant evidence. This includes:
- Medical reports from treating practitioners, including assessments of impairment and functional capacity
- Treatment records showing the type, frequency and duration of treatment
- Pay slips, tax returns or employment letters showing income loss
- Photographs of the accident scene, vehicle damage or injury symptoms
- Witness statements, if available
- Correspondence with the insurer, including emails and letters
If the insurer’s decision appears inconsistent with the law, a claimant may request a review by a claims assessor. This is not automatic and must be formally requested. The request should include all evidence and a clear explanation of why the decision is disputed.
Time Limits and Dispute Options
There is no fixed time limit to request a claims assessor review, but delays may affect the availability of evidence. It is best to act promptly after receiving an insurer’s decision. If a claimant has already been denied benefits or had payments stopped, they should not wait more than six months to seek a review, as delays may impact the ability to obtain medical records or witness testimony.
If the claims assessor upholds the insurer’s decision, the claimant may still apply to the NSW Civil and Administrative Tribunal (NCAT) for a review. NCAT has jurisdiction to hear disputes about CTP claims, including decisions made by claims assessors. The claimant must file an application within 12 months of the decision being made.
In regional NSW, claimants may face additional challenges in accessing legal advice or medical specialists. A claims assessor may take these barriers into account when assessing whether an insurer’s actions were reasonable. However, the assessor’s role is not to substitute for legal representation but to interpret the law and apply it fairly.
Hypothetical Example: A Regional Claimant’s Dispute
A cyclist in Wagga Wagga was struck by a car in a car park. The insurer denied weekly income payments, stating the injury was a threshold injury and that the claimant had not met the 52-week threshold for damages. The claimant provided medical evidence showing ongoing neurological symptoms, including numbness in the left arm, supported by MRI scans and a neurologist’s report.
The claims assessor reviewed the evidence and found that the injury involved a spinal nerve-root injury with neurological signs beyond radiculopathy, as defined in the Motor Accident Guidelines. This meant the injury qualified as a threshold injury under the Act, but the 52-week limit did not apply because the injury was not limited to threshold injuries. The assessor directed the insurer to reinstate weekly payments and to continue treatment and care benefits.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.