What Changed in NSW CTP Insurer Internal Reviews After 2017?
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).
The 2017 reforms to the NSW Compulsory Third Party (CTP) insurance scheme introduced a more structured and transparent process for challenging insurer decisions. Before these reforms, claimants often faced inconsistent internal review practices and limited clarity on how to request reconsideration. Since 2017, insurers are required to follow a formal internal review process under the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. This means that if an insurer denies a claim or refuses to pay a benefit such as weekly income payments, treatment and care benefits, or damages, the claimant can formally request an internal review. The insurer must then assess the decision again using the same criteria and evidence, and provide a written response within a defined timeframe.
What Must Be Included in a Formal Internal Review Request
To request an internal review, a claimant must submit a written request to the insurer. The request should clearly state the decision being challenged and include any new or previously unconsidered evidence. This may include updated medical reports, a detailed statement of the accident and injury, photographs of the scene or vehicle damage, and records of lost income. The insurer must acknowledge the request within 14 days and provide a final response within 30 days. If the insurer upholds the original decision, the claimant has the right to escalate the matter to the Personal Injury Commission (PIC) or, in some cases, to the State Insurance Regulatory Authority (SIRA) for review.
How to Challenge a Denied Claim Under the Revised System
If an insurer denies a claim or refuses to pay a benefit, the claimant must first exhaust the internal review process. This is a mandatory step before applying to the PIC. The claimant should not assume that a denial will automatically be overturned. The internal review is not a new assessment but a reconsideration of the original decision based on the same evidence and legal framework. The insurer must apply the Motor Accident Guidelines and the statutory thresholds for injury and damages. For example, if a claim is denied because the injury does not meet the threshold for damages, the insurer must demonstrate that the injury does not satisfy the criteria under section 3.11 of the Motor Accident Injuries Act 2017.
What Evidence Is Most Important in an Internal Review
The strongest evidence in an internal review includes medical reports from a treating practitioner that detail the nature, severity, and impact of the injury. Reports must show a clear link between the motor accident and the injury, including any ongoing symptoms, functional limitations, or treatment required. Photographs of the vehicle, the accident scene, and any visible injuries at the time of the accident can also support the claim. Income records showing loss of earnings or reduced capacity to work are essential for weekly income payment claims. Claimants should keep all correspondence with the insurer, including emails and letters, and note the date and time of any phone calls.
Time Limits and When to Seek Advice
There is no fixed statutory deadline for requesting an internal review, but it is best to act promptly. Delays may affect the insurer’s ability to verify evidence, particularly medical records or witness statements. If the insurer does not respond within 30 days, the claimant may proceed to the PIC. The PIC must be notified within 12 months of the insurer’s final decision, or the right to challenge the decision may be lost. It is advisable to seek advice from a qualified legal or claims professional before submitting a review request, especially if the claim involves a complex injury, a dispute over fault, or a potential claim for damages.
What If the Internal Review Is Unsuccessful?
If the insurer upholds its original decision after the internal review, the claimant may apply to the Personal Injury Commission (PIC). The PIC has the authority to review the insurer’s decision and determine whether it was correct under the law. The claimant must provide a complete record of the internal review process, including the insurer’s written response. The PIC may request additional medical evidence or hold a hearing. A claimant may also apply to SIRA for review if the matter involves a dispute over a statutory threshold injury or a claim for lifetime care. SIRA provides guidance on the process and timelines through its official website.
Practical Example: Internal Review in Auburn
A pedestrian in Auburn was struck by a car in a crosswalk in February 2024. The insurer initially denied a claim for treatment and care benefits, citing insufficient medical evidence of a permanent injury. The claimant submitted a new report from a specialist neurologist confirming a spinal nerve-root injury with neurological signs. The insurer conducted an internal review and, after reconsidering the evidence, approved the claim. This outcome was possible because the internal review process allowed for the submission of new medical evidence that had not been considered initially.
Next Steps for Claimants in NSW
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