Disputing an Insurer’s Decision on a CTP Claim in NSW
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 claim for compensation under the NSW Compulsory Third Party (CTP) insurance scheme has been denied, reduced, or delayed by an insurer, you have the right to request a reconsideration through an internal review. This process is a formal step within the CTP framework that allows you to ask the insurer to review its decision based on new or additional information. In Balmain and across NSW, injured road users, whether drivers, passengers, pedestrians, cyclists or motorcyclists, can initiate this process to challenge decisions about treatment and care benefits, weekly income payments, or damages. The internal review is not a court or tribunal, but it is a required step before escalating a dispute to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). The insurer must respond within a reasonable time, typically 28 days, and must provide a written explanation of its decision. You are not required to have legal representation to request an internal review, but it is often helpful to have your medical records and accident details ready.
What Evidence Is Needed for an Internal Review in Balmain?
To strengthen your internal review request, you should gather and submit evidence that supports your claim. This includes medical reports from your treating practitioner, including any assessments of your injury, treatment progress, and capacity to work. Photographs of the accident scene, if taken at the time, can help clarify how the incident occurred. A copy of the police report, if one was made, is also valuable. If you were not at fault or were partially at fault, details of any witness statements or video footage from nearby cameras may help. You should also include any correspondence with the insurer, including letters, emails, or SMS messages, to show the timeline of the dispute. For claims involving a motor vehicle accident in a private driveway or car park, the insurer may question whether the accident occurred on a public road. In such cases, evidence about the location, vehicle use, and whether the vehicle was in motion at the time may be critical. The Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017 set out the legal framework for what constitutes a motor accident under CTP law, and SIRA provides guidance on how insurers assess these matters.
How to Initiate an Internal Review of a CTP Claim Dispute
To begin an internal review, you must formally notify the insurer in writing. You can do this by email, letter, or through the insurer’s online claims portal if available. Your request should clearly state that you are appealing the insurer’s decision and reference the original claim number. Include a summary of the decision you are disputing, such as a refusal of weekly payments or a denial of treatment benefits. Attach all supporting evidence, including medical reports, income statements, and accident documentation. You should also state whether you are seeking a review of a decision made under the CTP scheme, and whether you have already received a formal letter from the insurer. The insurer is not required to accept your request, but they must acknowledge it and provide a response. If the insurer upholds its original decision, you may then apply to the Personal Injury Commission (PIC) for a review. The PIC is the independent body that handles disputes about CTP claims in NSW, and it can assess whether the insurer’s decision was reasonable under the law.
Time Limits for Disputing CTP Claim Decisions
There are time limits that apply to disputing CTP claim decisions in NSW. You must request an internal review within 60 days of receiving the insurer’s decision. If you miss this deadline, you may still be able to apply to the PIC, but the PIC may not accept your application if the delay is unexplained. The 60-day period starts from the date you received the written decision, not from when you first became aware of it. If you have not received a written response, you may still have time to request a review, but you should act promptly. The Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017 set out the procedural rules for claims, including timelines for internal reviews and appeals to the PIC. For example, if your claim involves a threshold injury, the insurer may limit treatment and care benefits after 52 weeks, unless you can show that the injury is not a threshold injury under the Motor Accident Guidelines. In such cases, a timely internal review may be essential to preserve access to care.
What Happens After an Internal Review Is Requested
After you submit your internal review request, the insurer must review your case and provide a written response. The insurer may confirm its original decision, modify it, or accept your arguments and change its position. If the insurer changes its decision, you should confirm in writing that you accept the new terms. If the insurer maintains its original decision, you have the right to apply to the Personal Injury Commission (PIC) for a review. The PIC will assess whether the insurer’s decision was reasonable based on the evidence and the law. You may need to attend a medical assessment with a doctor approved by the PIC, especially if there is a dispute about the nature or severity of your injury. The PIC can order the insurer to pay benefits, change the amount of weekly payments, or approve treatment. However, a review does not guarantee a different outcome, and the PIC’s decision is binding on the insurer.
When to Seek Legal Advice
If you are unsure about how to prepare your internal review request, or if the insurer has denied your claim on a technical ground, it may be wise to seek advice from a legal professional who understands CTP law in NSW. A solicitor can help you identify gaps in your evidence, draft a clear request, and ensure that you meet all procedural requirements. However, you are not required to have a solicitor to begin an internal review. The SIRA website provides information on the CTP claims process, including how to make a claim and what to do if a claim is disputed. The information on SIRA’s website is authoritative and reflects the current legal framework under the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017.
Hypothetical Example: A Cyclist’s Internal Review in Balmain
A cyclist in Balmain was struck by a car while riding on a bike path near the harbour. The insurer initially refused to pay for physiotherapy, claiming the injury was not a threshold injury. The cyclist submitted a medical report showing a diagnosed spinal nerve-root injury with neurological signs, which may qualify as a threshold injury under the Motor Accident Guidelines. The cyclist requested an internal review, including a copy of the MRI and a letter from the treating neurologist. The insurer reviewed the evidence and agreed to fund the treatment. This example shows how timely submission of medical evidence can influence an insurer’s decision during an internal review.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.