If your CTP claim has been rejected or you disagree with the insurer’s decision, understanding the internal review process is critical. In New South Wales, insurers must consider disputes before escalating to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). This article explains the early steps injured road users in Newcastle and Hunter should take when disputing a CTP claim decision, based on NSW law and SIRA guidelines.
What is an insurer’s internal review process for CTP claims?
Under NSW law, insurers must first review disputes internally before referring matters to SIRA or PIC. This process typically involves:
- Submitting a written request for reconsideration within 28 days of the decision
- Providing evidence to support your claim, such as medical records, accident reports, and witness statements
- Receiving a written response outlining the insurer’s revised position
The insurer must respond within 28 days. If they refuse to reconsider, you may escalate the matter to SIRA or PIC.
Practical steps for injured road users in Newcastle and Hunter
When disputing a CTP claim decision, take these steps:
- Gather evidence: Collect all medical records, accident reports, and correspondence with the insurer. SIRA requires detailed documentation to assess claims.
- Write a formal dispute request: Clearly state why you believe the insurer’s decision is incorrect. Reference specific sections of the Motor Accident Injuries Act 2017 if applicable.
- Follow up in writing: If the insurer delays or ignores your request, send a follow-up letter with proof of postage.
- Seek medical evidence: If your claim involves a threshold injury (e.g., soft tissue damage), ensure your medical records meet the spinal nerve-root qualification outlined in the Motor Accident Guidelines.
How SIRA’s guidance applies to internal reviews
SIRA’s guidelines state that insurers must consider all evidence before rejecting a claim. If your claim involves a threshold injury, the insurer must assess whether your injuries meet the criteria in the Motor Accident Guidelines. For example, a spinal nerve-root injury producing neurological signs may qualify as a threshold injury even if radiculopathy is not present.
Time limits and when to seek advice
You have 28 days to request an internal review after receiving the insurer’s decision. If the insurer refuses to reconsider, you may need to escalate the matter to SIRA or PIC. In Newcastle and Hunter, some insurers have regional offices that may handle disputes differently, so check with the insurer’s contact details.
When to seek legal advice
If your claim involves complex issues like:
- Disputes over weekly income payments
- Medical disputes requiring PIC review
- Lifetime care or workers’ compensation overlap
- Interstate claims or interstate insurers
You should consult a solicitor. Legal advice can help you navigate the internal review process and prepare for potential escalation to SIRA.
Example: Disputing a benefit reduction
Imagine a cyclist who suffered a soft-tissue injury in Newcastle. The insurer reduces their weekly income payment after 52 weeks, claiming only threshold injuries apply. The cyclist disputes this by submitting medical evidence showing their injury meets the spinal nerve-root criteria. The insurer reviews the evidence and revises the decision. This example illustrates how evidence and SIRA guidelines can influence outcomes.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.