What is an insurer internal review in a CTP claim?
An insurer internal review is a formal process within the Compulsory Third Party (CTP) insurance scheme in New South Wales where an injured person can request that the insurer reconsider a decision about their claim. This may occur if the insurer has denied a claim, refused a benefit such as weekly income payments or treatment and care benefits, or made a decision that the injured person believes is incorrect. In Albury and across NSW, this step is often taken before escalating a dispute to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
The internal review is not a new legal process but a mechanism for the insurer to reassess its original decision based on the evidence already provided. It is not a court or tribunal hearing, and the insurer remains the same entity making the final determination. The process is governed by the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017, which set out the framework for how disputes may be managed within the CTP scheme.
What questions should injured people ask during an internal review?
Injured people in Albury NSW should ask specific, evidence-based questions when requesting or participating in an internal review. These questions help clarify the insurer’s reasoning and ensure that the review is thorough and fair. Key questions include:
- What specific evidence did the insurer rely on when making the original decision?
- Was any medical report, accident statement, or witness information not considered?
- Is there a gap in the medical evidence that could support a claim for treatment and care benefits or weekly payments?
- Does the insurer acknowledge that the injury may have resulted from the motor accident, even if it is not classified as a threshold injury?
- Has the insurer reviewed the Motor Accident Guidelines, particularly regarding the assessment of soft tissue injuries and neurological signs?
These questions are not about challenging the insurer’s authority but about ensuring that the decision was made on a full and accurate assessment of the facts. In Albury, as elsewhere in NSW, the insurer must consider all available evidence, including medical reports, accident details, and any prior correspondence.
How does the CTP scheme handle disputes during internal reviews?
The CTP scheme in NSW does not require a dispute to be resolved through internal review before going to the PIC. However, the insurer must provide a written response to a request for internal review within 28 days of receiving it. If the insurer fails to respond within that time, the injured person may proceed to the PIC without further delay.
During the review, the insurer may request additional information, such as updated medical reports, a new assessment by a medical practitioner, or a statement from a witness. The injured person should provide any requested documentation promptly. The insurer must not unreasonably delay or withhold information.
If the internal review results in a decision that upholds the original denial or refusal, the injured person may then apply to the Personal Injury Commission (PIC) to review the decision. The PIC is an independent body that can assess whether the insurer’s decision was reasonable and in accordance with the Motor Accident Injuries Act 2017. The PIC process is separate from the internal review and allows for a formal review by a qualified tribunal member.
What are the legal boundaries of insurer internal reviews in NSW?
Insurer internal reviews in NSW are limited in legal effect. The insurer is not bound to change its decision simply because a review is requested. The review is internal to the insurer and does not alter the legal rights of the injured person. The insurer must still follow the law, including the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines.
A key legal boundary is that the insurer cannot deny benefits on the basis of a person’s fault in the accident. CTP compensation is not dependent on who caused the motor accident. The scheme is designed to provide prompt support to injured people regardless of fault.
Another boundary is the threshold injury rule. If a person’s only injuries are threshold injuries (such as soft tissue injuries), weekly benefits and treatment and care benefits are generally limited to 52 weeks from the date of the accident. The insurer must apply this rule correctly and cannot extend benefits beyond 52 weeks unless the injury is not a threshold injury or a medical review shows a change in condition.
The insurer must also comply with the 28-day response time. If the insurer does not respond within that period, the injured person may proceed to the PIC without waiting. This is a procedural right under the Motor Accident Injuries Regulation 2017.
Practical steps and evidence that matter
To strengthen a claim during an internal review, injured people in Albury should gather and preserve the following evidence:
- Medical reports from treating practitioners, including assessments of injury, treatment needs, and functional capacity.
- A copy of the accident report, including any police or witness statements.
- Photographs of the scene, vehicle damage, or injury symptoms taken soon after the accident.
- Records of lost income, including payslips, a letter from an employer, or a self-employment statement.
- Correspondence with the insurer, including emails, letters, and call logs.
A medical practitioner’s report that includes objective findings, such as imaging results, neurological signs, or functional limitations, is particularly important. For example, if a person has neck pain and radiating symptoms, a report that notes a positive Spurling’s test or MRI evidence of nerve root compression may support a claim for treatment and care benefits, even if the injury is classified as soft tissue.
When to seek advice
An internal review is not a substitute for independent legal advice. The process can be complex, and the insurer may not always apply the law correctly. In Albury, as in other parts of NSW, injured people should consider seeking advice if:
- The insurer has denied a claim based on a threshold injury classification.
- The insurer refuses to pay for treatment or care that is medically necessary.
- The insurer claims that the injury did not result from the motor accident, despite medical evidence to the contrary.
- The insurer delays or fails to respond within 28 days.
A qualified legal practitioner can help assess whether the insurer’s decision is legally sound and assist in preparing a formal submission to the PIC if necessary.
Hypothetical example
A 38-year-old Albury resident was a passenger in a car that was struck from behind at a traffic light. The driver was not at fault. The person reported neck and back pain immediately after the accident. A medical report confirmed soft tissue injury, but no fracture or disc herniation was found. The insurer initially refused treatment and care benefits, stating that the injury was a threshold injury and benefits would end after 52 weeks. The injured person requested an internal review, submitted a second medical report showing ongoing pain and limited range of motion, and asked the insurer to reconsider. The insurer upheld the original decision. The injured person then applied to the PIC for review, where a medical assessor confirmed that the injury was not resolved and that treatment was still required. The PIC ordered the insurer to resume benefits.
Next steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.