If you're dealing with an insurer dispute over caregiver costs in a NSW CTP claim, understanding the process is critical. Insurers in Illawarra and South Coast may conduct internal reviews to reassess claims before escalating to the Personal Injury Commission (PIC) or SIRA. This article explains how these reviews work, what evidence families should prepare, and how SIRA guidelines apply to caregiver claims.
How Insurers Handle Internal Reviews of Caregiver Claims
NSW CTP insurers must follow strict rules when reviewing claims involving caregiver costs. Under the Motor Accident Injuries Act 2017, insurers must consider whether the claimant’s injuries meet the 'threshold injury' criteria, which includes soft tissue injuries like whiplash. For caregiver claims, insurers evaluate whether the injury has resulted in a 'whole person impairment' or requires ongoing care.
Internal reviews typically focus on two areas: the medical evidence supporting the caregiver claim and the reasonableness of the care costs. Insurers may request additional documentation, such as medical reports from registered practitioners, care logs, or receipts for services. Families should ensure all records are accurate and clearly link the caregiver costs to the injury.
Evidence Families Should Keep During an Insurer Dispute
When disputing a decision, families must provide evidence that directly supports the caregiver claim. Key documents include:
- Medical records confirming the injury’s severity and treatment
- Caregiver’s employment details or independent contractor invoices
- A care plan from a registered nurse or occupational therapist
- Witness statements from family members or friends
- Photos of the accident scene or vehicle damage (if relevant)
Insurers may challenge claims by arguing the injury does not meet the threshold or that the care costs are excessive. Families should avoid making claims for 'non-essential' care unless it is explicitly recommended by a medical practitioner.
SIRA Guidelines for Internal Reviews
SIRA’s Motor Accident Guidelines (2023) state insurers must base decisions on clinical evidence, not assumptions. For example, if a claimant requires 20 hours of weekly care, the insurer must assess whether this aligns with the injury’s severity. SIRA also requires insurers to consider the claimant’s pre-accident lifestyle and whether the care is 'reasonably necessary' under the guidelines.
A practical example: A family in Wollongong claims their child needs 15 hours of weekly care after a threshold injury. The insurer disputes this, arguing the care is 'excessive.' The family must provide a medical report from a paediatrician confirming the child’s need for care, as well as evidence that the care plan was developed by a registered nurse.
Time Limits and When to Seek Advice
Insurers must respond to disputes within 28 days under the Motor Accident Injuries Act 2017. If they refuse to reconsider, families can escalate to SIRA or the PIC. However, time limits apply: claims must be submitted to SIRA within 52 weeks of the accident if the injury is a 'threshold injury.' For non-threshold injuries, the 52-week limit does not apply, but evidence must still be submitted promptly.
Families should seek legal advice if the insurer refuses to review the claim, if the care costs are disputed, or if the claimant’s condition worsens after the initial assessment. Legal professionals can help challenge decisions based on SIRA guidelines or request a medical review.
Next Steps for Families in Illawarra and South Coast
If your CTP claim is being disputed over caregiver costs, act quickly. Gather all medical and financial evidence, and request an internal review in writing. If the insurer refuses to reconsider, contact SIRA or a legal professional to explore further options. Every claim depends on its own facts, and families in regional NSW may need tailored advice to navigate the process.