What Changed in Insurer Internal Reviews After the 2017 Reforms
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 New South Wales' Compulsory Third Party (CTP) motor accident compensation scheme introduced significant changes to how insurers handle internal reviews of claim decisions. These changes, effective from 1 July 2018, altered the process for claimants seeking reconsideration of denied claims, particularly on the Central Coast. Key updates include stricter time limits for internal reviews, clearer documentation requirements, and revised pathways for escalating disputes to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
Under the reforms, insurers must now provide claimants with a written explanation of why a claim was denied, including the specific reasons for rejecting medical evidence or treatment. This transparency was introduced to reduce disputes over claim decisions. Additionally, claimants now have a limited timeframe, typically 28 days, to request an internal review after receiving a decision. This change was designed to streamline the dispute process and ensure timely resolution.
Practical Steps for Claimants on the Central Coast
If your CTP claim was denied, the first step is to request an internal review within the 28-day window. To support your case, gather all relevant evidence, including medical records, accident reports, and any correspondence with the insurer. Insurers often require detailed documentation to reassess claims, so ensure your records clearly show how the injury relates to the accident and meet the scheme's threshold injury criteria.
For example, if your claim was denied due to a disagreement over the severity of your injury, you may need to provide additional medical evidence, such as a revised assessment from a registered medical practitioner. Insurers also consider the 'whole person impairment' rating under the Motor Accident Guidelines, so ensure your medical team documents all relevant symptoms and functional limitations.
Time Limits and Dispute Pathways
The 2017 reforms also introduced stricter time limits for escalating disputes. If an internal review is denied, claimants must submit a formal objection to the PIC within 28 days of the review decision. This step is critical, as delays beyond this period may result in the claim being barred from further review. The PIC then has 21 days to respond, after which claimants may apply to SIRA for a review of the PIC's decision.
It's important to note that while the internal review process has become more structured, it does not guarantee a change in the insurer's decision. Disputes often hinge on the interpretation of medical evidence and whether the injury meets the scheme's threshold criteria. Claimants should seek legal advice if they believe their claim was unfairly denied or if they need assistance navigating the dispute pathway.
When to Seek Advice
The 2017 reforms have made the internal review process more complex, particularly for claimants unfamiliar with the new requirements. If your claim was denied, or if you're unsure how to proceed, it's advisable to consult a legal professional or a claims specialist. They can help you understand the evidence needed, ensure compliance with time limits, and assess whether your case meets the criteria for further review.
Next Steps
If you're on the Central Coast and facing a denied CTP claim, the first priority is to request an internal review within 28 days. Gather all relevant evidence and ensure your medical records clearly support your claim. If the review is denied, act quickly to submit an objection to the PIC. Remember, the 2017 reforms have changed the rules, so it's essential to understand how these changes apply to your specific situation. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.