What to Do If Your CTP Claim Is Disputed
If an insurer in New South Wales denies or reduces a motor accident compensation claim, such as a weekly income payment, treatment and care benefit, or damages, you can request an internal review. This is a formal process under the Motor Accident Injuries Act 2017 (MAIA) where the insurer must reconsider its decision based on new or additional evidence. The review is not a new legal proceeding, but a step to resolve disagreements before applying to the Personal Injury Commission (PIC).
How Insurers Conduct Internal Reviews
Under the MAIA, insurers must assess claims fairly and provide a written explanation for any decision. If you disagree, you may request an internal review within 28 days of receiving the decision. The insurer must respond within 28 days of receiving the request. This timeframe is not a statutory deadline but a practical expectation set by the State Insurance Regulatory Authority (SIRA).
The review is conducted by the insurer’s internal claims team, often with a different assessor than the original decision-maker. The insurer must consider any new evidence you provide, including updated medical reports, a formal treatment and care plan, proof of income loss, photographs of the accident scene or vehicle damage, and witness statements.
Common Reasons for Disputes and How to Address Them
Insurers often dispute claims on the following grounds, which may be reconsidered during an internal review:
- The injury does not meet the threshold for damages under MAIA s 3.11. This includes injuries classified as threshold injuries, such as soft tissue injuries with no permanent impairment.
- Treatment and care benefits are denied because medical evidence does not support a formal treatment plan or shows gaps in care.
- Weekly income payments are reduced or denied based on a medical assessment suggesting the claimant can return to work, even if they are still recovering.
- The claimant is found to have contributed to the accident (contributory fault), which may reduce or deny compensation.
SIRA provides guidance on responding to these issues, including sample letters and evidence checklists. However, the insurer is not required to change its decision simply because a review is requested. The review will be based on the same legal and evidentiary standards as the original assessment.
Practical Steps to Strengthen Your Review Request
To improve the chance of a favourable outcome, you should:
- Submit a written request for internal review within 28 days of receiving the insurer’s decision.
- Include all relevant evidence, such as:
- A new or updated medical report from your treating practitioner.
- A formal treatment and care plan signed by a medical practitioner.
- Payslips, employer letters, or tax returns showing income loss.
- Photographs of the accident scene, vehicle damage, or visible injury.
- Witness statements, if available.
- Clearly state which decision you are disputing and what outcome you seek (e.g., reinstatement of weekly payments, approval of a treatment plan).
When to Seek Independent Advice
An internal review does not guarantee a change in decision. If the insurer maintains its position, you may apply to the Personal Injury Commission (PIC) for a review. The PIC has authority under the MAIA to assess claims and may order a different outcome based on a fresh review of the evidence.
SIRA advises that claimants should not delay seeking legal advice if they believe the insurer’s decision is incorrect or if they are unsure how to present their case. A legal practitioner can help identify gaps in evidence, draft a stronger submission, or advise on whether a PIC application is appropriate.
Time Limits and Procedural Considerations
There is no statutory deadline for requesting an internal review. However, delays may affect the insurer’s ability to investigate the claim. SIRA recommends requesting a review as soon as possible after receiving a decision. If a claimant waits more than six months, the insurer may refuse to process the review on grounds of delay.
A review does not pause any time limits for other claims. For example, a claim for damages must still be made within three years of the accident under the Limitation Act 1969. The internal review process does not extend this deadline.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.