What changed about insurer internal reviews after NSW’s 2017 CTP 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 NSW’s Compulsory Third Party (CTP) scheme introduced significant changes to how insurers handle disputes over claim decisions. Under the new rules, claimants must now request an internal review of an insurer’s decision before escalating matters to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). This shift places greater responsibility on insurers to resolve disputes internally first, reducing the need for external intervention in many cases.
Key changes to insurer internal review processes
The 2017 reforms, under the Motor Accident Injuries Act 2017, clarified that insurers must provide claimants with a written opportunity to request a reconsideration of their decision. This process typically occurs within 28 days of the insurer’s initial decision, as outlined in SIRA’s guidelines for motor accident claims. Previously, claimants could directly escalate disputes to SIRA without first exhausting internal review options.
The revised framework also requires insurers to provide clear reasons for their decisions, ensuring claimants understand the basis of any denial or adjustment to their claim. This transparency helps reduce disputes by addressing misunderstandings early.
How to challenge an insurer’s decision under the new rules
If an insurer denies or adjusts a claim, the claimant must first submit a formal request for internal review. This should include:
- A clear statement of the claimant’s disagreement with the decision
- Supporting evidence, such as medical records, accident reports, or witness statements
- A request for the insurer to reconsider its decision based on the new evidence
Insurers are required to respond to these requests within 28 days, as per SIRA’s Making a motor accident claim guidelines. If the internal review does not resolve the dispute, the claimant may then escalate the matter to the PIC or SIRA.
Role of SIRA in regulating insurer reviews
SIRA oversees compliance with the new rules, ensuring insurers follow the correct procedures for internal reviews. The authority’s What you can claim page outlines the types of benefits available under the CTP scheme, including weekly payments for injuries and treatment costs. SIRA also provides templates and guidance for claimants seeking to challenge insurer decisions, ensuring consistency across the state.
Practical steps for claimants in Greater Sydney
Claimants in Greater Sydney should:
- Submit an internal review request within 28 days of the insurer’s decision
- Keep copies of all correspondence with the insurer
- Gather evidence such as medical reports, accident scene photos, and witness statements
- Seek legal advice if the insurer’s decision appears to breach the 2017 reforms
When to seek independent legal advice
If the insurer’s internal review denies the claim or fails to address key concerns, claimants should consider consulting a solicitor. Legal professionals can help identify whether the insurer has adhered to the revised rules and whether further action, such as a dispute resolution application to the PIC, is necessary.
Time limits and next steps
Claimants must act quickly. Under the 2017 reforms, the 28-day internal review period is strict, and missing it may prevent further action. If the insurer’s decision is unsatisfactory, the claimant has three months from the date of the internal review response to escalate the matter to the PIC or SIRA.
Final note on dispute resolution
Internal reviews are not guarantees of success. Insurers may still uphold their decisions if the claimant’s evidence does not meet the threshold injury criteria or if the claim is found to be ineligible under the CTP scheme. However, the revised rules provide a clearer pathway for claimants to challenge decisions and ensure their rights are protected under the new framework.
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