Understanding Insurer Internal Reviews in NSW CTP Claims
If you are a caregiver or family member involved in a motor accident claim in New South Wales, you may need to request an internal review of a decision made by the insurer. This process allows you to ask the insurer to reconsider its decision on benefits, such as treatment and care, weekly income payments, or damages. In Greater Sydney, as elsewhere in NSW, these reviews are governed by the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. The insurer must review your request within a specified timeframe, and you have the right to submit additional information or evidence to support your case.
How Caregiver and Family Circumstances Are Considered
Insurers are required to assess all relevant factors when making decisions about compensation. This includes the impact of the injury on the injured person’s ability to perform daily tasks, including care for dependants. If a family member has become a caregiver due to the injury, the insurer must consider the time spent, the nature of the care provided, and any financial or personal costs incurred. This may include time spent transporting the injured person to medical appointments, assisting with household tasks, or providing emotional support.
The insurer is not required to pay a separate benefit for caregiving, but the extent and nature of caregiving may be considered when assessing the overall impact of the injury. For example, if the injured person was previously the primary caregiver for a child or elderly relative, and now requires care themselves, the insurer may take this into account when assessing future care needs or long-term dependency.
Practical Steps and Evidence to Support Your Review
To strengthen your internal review request, gather and submit evidence that demonstrates the actual burden placed on the caregiver or family. This may include:
- A written statement from the caregiver outlining the time spent, tasks performed, and any changes to their routine or employment.
- Medical reports that confirm the injured person’s need for assistance with daily activities.
- Records of out-of-pocket expenses related to care, such as transport costs or modifications to the home.
- Copies of correspondence with the insurer, including any decisions you are challenging.
If the injured person is a child, the family may need to show how the injury has affected their education, social participation, or emotional wellbeing. These factors may be relevant to the assessment of future care needs or impairment.
Time Limits and Dispute Pathways
You must request an internal review within 28 days of receiving the insurer’s decision. Failure to do so may result in the loss of the right to challenge the decision through this process. The insurer must respond within 28 days of receiving your request. If the insurer upholds its original decision, you may then apply to the Personal Injury Commission (PIC) for a review. The PIC can assess whether the insurer’s decision was reasonable and may order a different outcome.
A common issue in Greater Sydney is the timing of medical assessments. If a medical report was issued before the internal review was submitted, and it contradicts the insurer’s assessment, you may request a review of the medical evidence. However, the insurer is not required to accept new medical evidence unless it was not previously available. The PIC may order a new assessment if it finds the original assessment was flawed.
When to Seek Independent Advice
Internal reviews are not a substitute for legal advice. While the insurer must consider your concerns, they are not required to change their decision simply because a family member disagrees. If the review is denied, and you believe the decision was not reasonable, you may need to seek independent legal advice before applying to the PIC. The PIC process is more formal and may involve a hearing.
A hypothetical example: A mother in Sydney’s western suburbs became the primary caregiver for her teenage son after he sustained a spinal injury in a car accident. She reduced her work hours to provide care and support. When the insurer denied her claim for loss of income due to caregiving, she submitted a detailed statement, medical reports, and pay stubs showing reduced earnings. The internal review upheld the decision, citing that caregiving was not a financial loss under the Act. She then applied to the PIC, where her evidence was accepted as part of the overall assessment of impact.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.