If your insurer has denied or limited your Compulsory Third Party (CTP) scheme entitlements, you may be able to request an internal review before escalating the dispute. This guide explains how to challenge an insurer's decision about your eligibility for CTP benefits in the Newcastle and Hunter region, based on NSW law.
What is an insurer internal review?
Insurers must consider your claim under the Motor Accident Injuries Act 2017 and Motor Accident Injuries Regulation 2017. If your claim is denied or limited, you can ask the insurer to review its decision. This process lets you provide additional evidence or clarify misunderstandings without involving the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
How to request an internal review
To start an internal review, contact your insurer's claims department in writing. Clearly state:
- The date of your accident and claim
- The insurer's decision date
- Why you believe the decision is incorrect
- Any new evidence (e.g., medical records, accident reports)
Insurers must respond within 21 days. If they reject your request, you may need to escalate the matter.
SIRA's role in eligibility disputes
SIRA provides guidelines for determining CTP scheme eligibility. For example, your injury must meet the 'threshold injury' criteria under the Motor Accident Guidelines. If your insurer disputes whether your injury qualifies, SIRA's guidelines help assess whether your claim meets the legal definition of a 'threshold injury' or 'soft tissue injury' under the scheme.
Key legal boundaries for claimants
- Time limits: You must request an internal review within 21 days of the insurer's decision. If you miss this deadline, you may lose the right to challenge the decision.
- Evidence requirements: Insurers must consider your claim based on the evidence you provide. If your claim is denied, you may need to submit additional medical reports or accident details.
- No automatic right to change decisions: An internal review does not guarantee your claim will be approved. Insurers must apply the law as written, including the 52-week limit for weekly benefits after threshold injuries.
Practical steps to take
- Gather evidence: Collect medical records, accident reports, and any correspondence with the insurer.
- Document your claim: Keep a record of all communications and evidence.
- Seek advice: If your insurer refuses to review your claim, contact the PIC or SIRA. In Newcastle and Hunter, the PIC has offices in Newcastle and Maitland.
Example: A common eligibility dispute
Imagine a pedestrian injured in a car accident in Newcastle. The insurer denies the claim, arguing the injury does not meet the 'threshold injury' definition. The claimant requests an internal review, providing medical evidence of a spinal nerve-root injury. The insurer reviews the evidence and may reconsider the claim based on SIRA's guidelines.
When to escalate to SIRA or PIC
If your insurer refuses to review your claim or the review outcome is unsatisfactory, you may need to escalate the matter. The PIC handles disputes about whether your injury meets the legal definition of a 'threshold injury' or 'soft tissue injury'. SIRA oversees the PIC's decisions.
Next steps
CTP scheme eligibility depends on the date of your accident, your injury, and the insurer's decision timeline. To discuss your circumstances, complete the quick, no obligation enquiry form. Every claim depends on its own facts.