Understanding Insurer Internal Reviews in NSW CTP Claims
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 motor accident compensation claim has been declined or limited by your insurer, you may request an internal review. This is a formal process within the insurer’s own procedures to reconsider their decision. In New South Wales, this step is part of the CTP (Compulsory Third Party) claims pathway under the Motor Accident Injuries Act 2017. It is not a legal proceeding, but it can resolve disputes before escalating to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
In Greater Sydney, claimants frequently use internal reviews to challenge decisions on weekly income payments, treatment and care benefits, or eligibility for damages. Insurers must assess these requests within a reasonable timeframe, typically 28 days, and provide written reasons for their decision. The process is designed to allow a fair reconsideration of evidence, including medical reports, accident details, and financial documentation.
The Legal Framework for Internal Reviews in NSW
The Motor Accident Injuries Act 2017 (MAIA) governs CTP claims in NSW. Under this law, insurers are required to assess claims fairly and in good faith. An internal review is not a statutory right, but insurers are expected to have internal processes that comply with the Act and the Motor Accident Injuries Regulation 2017.
SIRA, the State Insurance Regulatory Authority, oversees CTP claims and provides guidance on insurer conduct. While SIRA does not directly manage internal reviews, it expects insurers to follow fair and transparent procedures. If an insurer fails to act reasonably during an internal review, the claimant may later seek review by the Personal Injury Commission (PIC), which has authority to determine disputes on entitlements, damages, and medical assessments.
Practical Steps and Evidence That Matter
To strengthen your internal review request, gather and submit the following evidence:
- A copy of the insurer’s original decision letter
- All medical reports, including assessments from your treating practitioner and any specialist
- Photographs of the accident scene, vehicle damage, or injury manifestations
- Witness statements, if available
- Records of lost income, including payslips and employer letters
- Correspondence with the insurer, including emails and letters
In Greater Sydney, claimants have successfully challenged decisions on weekly payments by providing consistent medical evidence showing ongoing capacity to work. For example, a driver injured in a rear-end collision in North Sydney submitted a series of physiotherapy reports showing progressive recovery and returned to part-time work. The insurer initially refused a return to full-time hours, but after a detailed internal review including a new medical assessment, the decision was revised.
When to Escalate: Time Limits and Dispute Pathways
There is no fixed legal deadline for requesting an internal review, but delays may affect your ability to claim later, particularly if you are pursuing damages. Under MAIA, claims for damages must generally be made within three years of the accident date. However, if you are relying on a medical dispute, the PIC may require you to exhaust internal review processes before accepting a dispute.
If your internal review is denied or not responded to within a reasonable period, you may apply to the Personal Injury Commission (PIC). The PIC handles disputes on entitlement to weekly payments, treatment and care benefits, and damages. It also manages medical disputes, including those involving whole person impairment (WPI) assessments.
A claimant in Bondi who was denied a damages claim due to a threshold injury (defined under the Motor Accident Guidelines) successfully appealed after an internal review failed to properly consider a spinal nerve-root injury with neurological signs. The PIC later accepted that the injury met the threshold definition and allowed a damages claim.
What You Should Know About Internal Review Outcomes
An internal review does not guarantee a change in decision. Insurers may uphold their original position, even after reviewing new evidence. However, a formal review can result in a revised decision, particularly if the insurer identifies a procedural error or overlooked medical information.
If the insurer refuses to change their decision, you may still proceed to the PIC. The PIC will not accept a claim for dispute resolution unless you have first attempted to resolve the matter through the insurer’s internal review process, unless there was a failure to respond.
Hypothetical Example: Internal Review in a Sydney Inner West Accident
A cyclist in Marrickville was struck by a car at a traffic light in 2024. The insurer initially denied weekly income payments, citing insufficient evidence of ongoing capacity to work. The claimant submitted a medical report from their GP confirming ongoing neck pain and restricted mobility, along with a diary of work absences. After a formal internal review, the insurer revised its decision and approved 12 weeks of payments. The claimant later applied to the PIC for a longer period, which was granted after a medical dispute was resolved.
Next Steps: When to Seek Advice
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