What to Expect During an Insurer's Internal Review of a CTP Claim
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
If you're injured in a motor accident in NSW and your claim is disputed, you may need to request an internal review by the insurer. This process is governed by the Motor Accident Injuries Act 2017 and SIRA guidelines. Injured people in Ballina often ask questions about how to challenge a decision, what evidence is needed, and whether they can escalate the matter. This article explains the process and answers common concerns.
How Insurers Handle Disputes Through Internal Reviews
When an insurer disputes a CTP claim, they typically review the decision internally before escalating it to the Personal Injury Commission (PIC) or SIRA. The review considers factors like medical evidence, claim forms, and policy terms. Insurers may request additional documentation or reassess the injury's severity. Injured individuals should ask:
- What specific part of my claim is being disputed?
- Can I submit new medical records or evidence?
- How long will the review take?
Insurers must provide a written response explaining their decision. If they reject the claim, you may need to escalate it for further review.
Practical Steps for Injured People in Ballina
If your claim is disputed during an internal review, take these steps:
- Request a written explanation of the insurer's decision, including the reasons for the dispute.
- Gather supporting evidence, such as medical reports, accident records, and witness statements. SIRA guidelines emphasize the importance of accurate medical documentation.
- Submit additional information if the insurer requests it, ensuring it directly addresses the disputed issue.
- Escalate to SIRA if the insurer refuses to reconsider the claim. SIRA can review claims where the insurer's decision is unclear or where there's a disagreement about the injury's severity.
Time Limits and When to Seek Advice
NSW CTP claims must be submitted within 52 weeks of the accident, but disputes can arise at any time. If your claim is rejected or delayed, act quickly. SIRA guidelines state that claims must be reviewed within 28 days of submission, though this can extend if more information is needed.
If you're unsure whether your claim meets the threshold injury criteria or if the insurer is withholding benefits, seek legal advice. SIRA's internal review process can be complex, and injured individuals may need assistance to challenge a decision effectively.
Example: A Common Dispute Scenario
Consider a cyclist injured in a collision where the insurer disputes the claim, arguing the injury is 'soft tissue' and not severe enough. The injured person may ask: Why is my claim being rejected? Under SIRA guidelines, soft tissue injuries must meet specific criteria, such as spinal nerve-root damage or neurological signs. If the medical evidence supports a threshold injury, the insurer must reconsider the claim.
Next Steps for Injured People in Ballina
If your CTP claim is disputed during an internal review, ensure you understand the insurer's reasoning and gather all relevant evidence. Time limits apply, and delays can affect your ability to claim benefits. For personalized guidance, complete the quick, no obligation enquiry form to discuss your circumstances.