Understanding Insurer Internal Reviews for CTP Scheme Eligibility
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 motor accident compensation in New South Wales has been denied or limited by an insurer on the basis of scheme eligibility, you may be entitled to request an internal review. This process allows the insurer to reconsider their decision based on new or additional information. In Greater Sydney, as across NSW, this internal review is a formal step under the Motor Accident Injuries Act 2017 (MAIA) and must be followed before escalating a dispute to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
The insurer must provide written notice of their decision, including the reasons for denying or limiting your claim. You have the right to submit further evidence or arguments in response. The review must be completed within 28 days of receiving a request, unless the insurer provides a written extension. This timeframe is critical, as delays may affect your ability to pursue external review options.
What Determines Scheme Eligibility Under NSW Law
Under the NSW CTP scheme, eligibility for benefits such as treatment and care, weekly income payments, and damages depends on several legal factors. The insurer must assess whether you meet the criteria under the MAIA, including whether your injuries are considered threshold injuries, whether you have a whole person impairment (WPI) of at least 10%, and whether you have sustained a permanent impairment that affects your capacity for work or daily activities.
A claim may be denied if the insurer determines that your injuries do not meet the threshold for damages, or if they believe you are not entitled to weekly payments due to insufficient loss of income. These determinations are based on medical evidence, employment records, and the Motor Accident Guidelines. The insurer must apply the law consistently and cannot deny eligibility based on personal opinion or assumptions.
Evidence That Supports a Dispute Over CTP Scheme Eligibility
To successfully challenge an insurer’s decision on scheme eligibility, you must provide clear and credible evidence. This includes:
- A detailed medical report from your treating practitioner, including diagnosis, treatment provided, and prognosis.
- Evidence of loss of income, such as payslips, tax returns, or a letter from your employer confirming reduced hours or inability to work.
- Photographs of the accident scene, vehicle damage, or injuries sustained.
- Witness statements, if available, confirming the circumstances of the accident.
- A copy of the accident report, if one was filed with the police or NSW Police.
The insurer is required to consider all submitted evidence. If you believe the insurer has not properly assessed your medical condition or has misapplied the Motor Accident Guidelines, you may request a review of the medical assessment. This may involve a second opinion or a review by a medical practitioner appointed under the PIC process.
Time Limits and Next Steps After an Internal Review
There is no automatic right to a review, but you may request one within 28 days of receiving the insurer’s written decision. If the insurer does not respond within 28 days, you may proceed to external review. If the internal review results in a decision that upholds the original denial, you may then apply to the Personal Injury Commission (PIC) for a determination.
The PIC has the authority to review eligibility decisions, including those involving threshold injuries, WPI, and entitlement to damages. You must apply within 12 months of the insurer’s final decision, unless a longer period applies under transitional arrangements. The PIC will assess whether the insurer correctly applied the law and whether the evidence supports the decision.
When to Seek Independent Legal Advice
An internal review does not guarantee a change in decision. The insurer may uphold their original position, and you may still need to pursue a formal dispute through the PIC. At this stage, independent legal advice is strongly recommended. A solicitor experienced in CTP claims can help you:
- Interpret the insurer’s reasoning and identify legal errors.
- Prepare a submission outlining why the insurer’s decision was incorrect.
- Liaise with medical assessors and ensure your medical evidence is properly presented.
For example, if your insurer denied damages because they considered your injury a soft-tissue injury without neurological signs, but your MRI shows a spinal nerve-root injury with objective signs of nerve dysfunction, a legal expert can argue that this falls within the definition of a threshold injury under the Motor Accident Guidelines.
Practical Steps to Take Now
If you have received a decision from your insurer that you believe is incorrect, act promptly. Gather all relevant documents, including medical reports, correspondence, and proof of income loss. Submit a written request for an internal review within 28 days. Keep a copy of all correspondence and note the date of submission.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.