Insurer Internal Reviews for 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 insurer disputes a decision about your NSW Compulsory Third Party (CTP) claim, you may need to request an internal review before escalating the matter to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). This process is designed to resolve disputes without immediately involving external bodies. Understanding how insurers handle internal reviews is essential for injured people in Bankstown seeking fair treatment.
How Insurer Internal Reviews Work
Insurers must follow specific rules when reviewing claims. If your claim is denied or adjusted, you can ask the insurer to reconsider its decision. This is called an 'internal review' and is a formal step before escalating to PIC or SIRA. The insurer must provide a written response explaining its decision, including reasons for any changes.
Key points to note:
- Insurers must act within 28 days of receiving your internal review request.
- You can request a review by writing to the insurer, clearly stating your disagreement and supporting evidence.
- If the insurer refuses to review or changes its decision, you may need to escalate the matter to PIC or SIRA.
Common Questions Injured People Ask
Injured people in Bankstown often ask:
- What happens if my insurer disputes my claim?
If your insurer disputes your claim, it must provide a written explanation. You can challenge the decision by submitting new evidence or requesting a review.
- How long does an internal review take?
Insurers have 28 days to respond to a review request. Delays may indicate a need for further action.
- Can I challenge the insurer's decision without involving SIRA?
Yes, but you must first exhaust the insurer's internal review process before escalating to SIRA.
SIRA Guidelines for Internal Reviews
SIRA provides guidelines to help injured people understand their rights during internal reviews. These include:
- Requiring insurers to provide clear reasons for denying or adjusting claims.
- Allowing claimants to submit additional evidence during reviews.
- Ensuring that decisions are made within set time limits.
SIRA also emphasizes that insurers must act fairly and transparently. If you believe your insurer has acted unreasonably, you can request a review of the review process itself.
Steps to Take if Your Claim is Disputed
If your insurer disputes your claim, take these steps:
- Request an internal review in writing, clearly stating your disagreement and supporting evidence.
- Keep records of all correspondence, including dates and copies of emails or letters.
- Gather evidence such as medical reports, accident reports, and witness statements.
- Escalate to PIC or SIRA if the insurer refuses to review or changes its decision.
When to Seek Legal Advice
If your insurer's internal review is denied or you are unsure about your options, consider seeking legal advice. A solicitor can help you understand your rights and whether you can challenge the insurer's decision further.
Example Scenario
Imagine you were injured in a car accident in Bankstown and submitted a CTP claim. Your insurer denied the claim, stating it was not a 'threshold injury.' You request an internal review, providing medical evidence showing your injury meets the threshold. The insurer reviews its decision and agrees to pay. This shows how internal reviews can lead to fair outcomes.
Next Steps
CTP claims depend on the specific facts of your case. If you are unsure about your insurer's decision or need help with an internal review, complete the quick, no obligation enquiry form to request contact about your circumstances.