What Happens During an Insurer’s Internal Review of a CTP Claim Related to Daily Activities?
When an insurer disputes a claimant’s ability to return to daily activities following a motor accident in New South Wales, the insurer must first conduct an internal review under the Motor Accident Injuries Act 2017. This process allows the insurer to reassess the claim based on available medical and factual evidence before deciding whether to accept or reject the claim. The internal review is not a formal legal hearing but a procedural step within the CTP compensation framework. It typically involves a review of medical reports, treatment records, and the claimant’s functional capacity as described in their statement. Insurers may request additional medical assessments, including a medical practitioner’s report under the Motor Accident Injuries Regulation 2017, to determine whether the claimant has recovered sufficiently to resume normal daily activities.
What Factors Do Insurers Consider When Assessing Disputes About Returning to Daily Activities?
Insurers assess disputes about returning to daily activities by examining objective and subjective evidence of functional recovery. Key factors include:
- The nature and severity of injuries sustained in the accident, particularly soft tissue injuries or musculoskeletal conditions.
- Medical evidence showing ongoing pain, restricted movement, or functional limitations that affect daily tasks such as walking, lifting, driving, or household chores.
- The claimant’s capacity to perform work, household duties, social activities, and self-care, as documented in medical reports and personal statements.
- Whether the claimant has received treatment for pain, mobility issues, or psychological impact, and whether treatment has been discontinued or is ongoing.
- The consistency of the claimant’s statements over time, including any changes in reported symptoms or functional ability.
The Motor Accident Injuries Guidelines set out the standard for evaluating functional capacity. Insurers must apply these guidelines when reviewing claims, particularly in relation to the assessment of whole person impairment and the impact of injuries on daily life. A claimant’s return to daily activities is not determined solely by their self-report but by a combination of medical evidence and functional assessment.
How Can Claimants Challenge an Insurer’s Decision to Dispute Their Ability to Perform Daily Activities?
If an insurer rejects or limits benefits during an internal review, the claimant may challenge the decision by requesting a review from the Personal Injury Commission (PIC). The PIC is the independent body responsible for resolving disputes under the CTP scheme in NSW. To initiate a dispute, the claimant must provide updated medical evidence, including a report from a medical practitioner assessing functional capacity and the impact of injuries on daily activities. The PIC may order a medical assessment to resolve discrepancies in evidence.
A claimant may also request a review of the insurer’s internal decision by submitting a written request, supported by evidence such as:
- A detailed medical report from a treating practitioner outlining functional limitations.
- A diary or log of daily activities, including difficulties experienced.
- Photographs or videos showing limitations in movement or tasks.
- Witness statements from family, friends, or employers describing changes in the claimant’s daily functioning.
The internal review process must be completed within 28 days of the insurer receiving a request for review. If the insurer does not respond within that timeframe, the claimant may proceed directly to the PIC. The PIC will assess the evidence independently and may uphold, vary, or overturn the insurer’s position.
Time Limits, Disputes and When to Seek Advice
There is no fixed deadline for requesting an internal review, but it is advisable to act promptly to preserve evidence and avoid delays in receiving benefits. If the insurer has already made a decision to dispute the claim, the claimant must notify the insurer in writing within 14 days of receiving the decision to request a review. Failure to do so may affect the ability to challenge the decision later.
Disputes about returning to daily activities often involve complex medical and factual issues. Insurers may rely on a single medical report to assess recovery, while claimants may rely on ongoing symptoms and functional limitations. The Motor Accident Injuries Act 2017 provides that a claimant may be entitled to treatment and care benefits and weekly income payments for up to 52 weeks if their only injuries are threshold injuries. However, if the claimant has not recovered to a point where they can resume daily activities, benefits may continue beyond that period.
A claimant should seek independent legal or medical advice if the insurer disputes their ability to return to daily activities and the medical evidence is conflicting. A medical practitioner’s report that details functional capacity and the impact of injuries on daily life can be critical in resolving disputes. The claimant should also keep a record of all correspondence with the insurer, including emails, letters, and call logs.
Hypothetical Example: A Claimant in Greater Sydney Challenging an Insurer’s Decision
A 42-year-old driver in Sydney’s western suburbs was involved in a rear-end collision in June 2024. She sustained a soft tissue injury to her neck and back, and reported ongoing pain and difficulty performing household tasks. Her insurer initially accepted her claim but later disputed her ability to return to daily activities, citing a medical report stating she had recovered. She submitted a diary showing her inability to lift groceries, drive for long periods, or care for her children. She also provided a report from her treating physiotherapist detailing ongoing functional limitations. She requested an internal review, which the insurer completed within 28 days. The insurer maintained its position. She then applied to the PIC for a review, which ordered a new medical assessment. The PIC ultimately accepted her claim for ongoing treatment and care benefits, acknowledging that her injuries had not resolved and that she had not returned to her pre-accident level of daily functioning.
Next Steps: What Should You Do Now?
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