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).
If your insurer disputes a Compulsory Third Party (CTP) claim in New South Wales, you have options to challenge their decision. This article explains the internal review process, dispute resolution mechanisms, and how to escalate claims in Greater Sydney. NSW CTP rules require insurers to reconsider claims before external review, and SIRA provides pathways for resolving disputes.
Internal Review Process
When an insurer denies or reduces a CTP claim, the claimant can request an internal review. This process allows the insurer to reassess their decision based on new evidence or reconsideration of existing information. Under the Motor Accident Injuries Act 2017, insurers must provide a written response within 28 days of receiving the review request. Key steps include:
- Documenting the dispute: Keep records of all correspondence, medical reports, and evidence supporting your claim.
- Requesting a review: Submit a formal written request to the insurer, clearly stating your position and referencing the claim number.
- Time limits: Insurers have 28 days to respond to internal review requests. If they fail to act within this timeframe, you may escalate the matter.
Dispute Resolution Options
If the insurer’s internal review does not resolve the dispute, you can pursue alternative resolution methods. These include:
1. Mediation through SIRA
The State Insurance Regulatory Authority (SIRA) offers mediation services to resolve disputes between claimants and insurers. Mediation is a voluntary process where a neutral third party helps both sides reach an agreement. It is typically used for claims involving:
- Disagreements over the extent of injuries.
- Disputes about the amount of compensation.
- Conflicts over the interpretation of policy terms.
To access mediation, you must first exhaust the insurer’s internal review process. SIRA will assess whether your case is suitable for mediation based on its complexity and the parties’ willingness to negotiate.
2. Escalation to the Personal Injury Commission (PIC)
If mediation fails or is not appropriate, you may escalate the dispute to the Personal Injury Commission (PIC). The PIC handles disputes related to medical assessments, such as disagreements over the severity of injuries or the appropriateness of treatment. This process is distinct from SIRA’s mediation and is governed by the PIC’s rules.
3. Legal Action
As a last resort, you may seek legal advice to pursue a claim through the NSW Civil and Administrative Tribunal (NCAT) or the courts. This option is typically reserved for complex cases where there is a clear legal basis for challenging the insurer’s decision.
SIRA’s Role in Dispute Resolution
SIRA plays a critical role in overseeing the CTP claims process and resolving disputes. Its responsibilities include:
- Monitoring insurer compliance: Ensuring insurers adhere to the Motor Accident Injuries Act 2017 and its regulations.
- Providing mediation services: Facilitating voluntary mediation to resolve disputes between claimants and insurers.
- Escalating serious issues: Referring cases to the PIC or other regulatory bodies when insurers fail to comply with their obligations.
SIRA’s mediation services are free of charge, but you must first attempt the insurer’s internal review before accessing these options.
Practical Steps for Claimants
If your insurer disputes your CTP claim, take the following steps:
- Request an internal review: Submit a written request to the insurer, clearly stating your position and referencing the claim number. Include any new evidence that supports your claim.
- Gather medical evidence: Ensure all medical records, treatment plans, and expert opinions are up to date. These documents are crucial for demonstrating the extent of your injuries.
- Seek clarification on disputes: If the insurer’s decision is unclear, ask for a written explanation of their reasoning. This can help identify gaps or errors in their assessment.
- Escalate if necessary: If the internal review fails to resolve the dispute, contact SIRA to explore mediation or escalate to the PIC.
Hypothetical Example
Consider a scenario where a claimant is denied a CTP claim because their injuries do not meet the threshold injury criteria. After requesting an internal review, the claimant provides additional medical evidence showing a spinal nerve-root injury with neurological signs. The insurer reconsiders the claim and approves it. This example illustrates how new evidence can lead to a revised decision.
When to Seek Advice
If your insurer disputes your claim and the internal review process does not resolve the issue, it is advisable to seek legal advice. A solicitor can help you navigate the dispute resolution options, prepare for mediation or legal action, and ensure your rights under the Motor Accident Injuries Act 2017 are protected.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.