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 you're on the Central Coast and your insurer has denied or limited your CTP claim, you may be wondering how to challenge their decision. Under NSW law, injured road users have specific rights to request an internal review of insurer decisions before escalating to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). This article explains how the internal review process works, what evidence you need, and when to seek legal advice.
What is an insurer internal review and how does it work in NSW CTP claims?
An insurer internal review is a formal process where you can ask your claimant’s insurer to reconsider their decision. This applies when your claim has been denied, limited, or rejected. Under the Motor Accident Injuries Act 2017, insurers must provide a written explanation for their decision and allow you to request a review.
The review process typically involves submitting a written request to the insurer, outlining why you believe their decision was incorrect. The insurer must then reassess your claim based on the evidence provided. This process is designed to resolve disputes without escalating to the PIC or SIRA.
How can injured people request an internal review of an insurer's decision?
To request an internal review, you must submit a written application to the insurer. This should include:
- A clear statement of your request for a review
- Details of the insurer’s previous decision
- Supporting evidence to challenge the decision
- Your contact information
The insurer must respond within 28 days of receiving your request. If they refuse to change their decision, you may then escalate the matter to the PIC or SIRA.
What evidence is needed to support a dispute with an insurer's internal review?
Insurers rely on evidence to assess claims. To challenge a decision, you must provide:
- Medical records confirming your injury and treatment
- Accident reports or police statements
- Witness statements or contact details
- Proof of income loss or other claimed consequences
- Any correspondence with the insurer
Medical evidence is particularly critical. For example, if your injury is classified as a 'threshold injury' under the Motor Accident Guidelines, you must show that your symptoms meet the specific clinical criteria. SIRA guidelines state that insurers must assess claims based on objective medical evidence, not subjective claims.
How does SIRA regulate insurer internal review processes for CTP claims?
SIRA oversees the CTP scheme and ensures insurers comply with the Motor Accident Injuries Act 2017. While SIRA does not directly handle internal reviews, it sets the standards insurers must follow. For example, insurers must:
- Provide a written explanation for denied claims
- Allow a reasonable time for internal review
- Consider all relevant evidence before making a final decision
If an insurer fails to follow these rules, you can escalate the matter to SIRA. However, SIRA typically only intervenes in cases of systemic non-compliance, not individual disputes.
Practical steps for injured people on the Central Coast
- Request an internal review in writing within 28 days of the insurer’s decision. Include all relevant evidence.
- Keep copies of all correspondence with the insurer, including dates and reference numbers.
- Seek medical evidence that clearly links your injury to the accident. This includes specialist reports and clinical notes.
- Escalate to the PIC if the insurer refuses to change its decision. The PIC handles disputes about the medical evidence or the insurer’s interpretation of the guidelines.
When to seek legal advice
If your insurer’s decision is based on a misunderstanding of the law or medical evidence, a solicitor can help. Legal advice is particularly useful if:
- Your claim involves a dispute over the 'threshold injury' classification
- You believe the insurer has misinterpreted the Motor Accident Guidelines
- You need assistance with the PIC or SIRA application process
Legal professionals can also help you understand the implications of a 'blameless accident' or how to handle claims involving multiple insurers.
Example: A Central Coast case
Consider a scenario where a driver on the Central Coast is involved in a collision and later develops chronic back pain. The insurer initially denies the claim, citing no 'threshold injury.' The injured person requests an internal review, providing a specialist’s report confirming a spinal nerve-root injury with neurological signs. The insurer then reclassifies the injury as a threshold injury and approves benefits. This example shows how medical evidence can change an insurer’s decision.
Time limits and next steps
You have 28 days to request an internal review after the insurer’s decision. If the insurer refuses to change its decision, you must escalate the matter to the PIC within 28 days of the review outcome. If the PIC also rejects your claim, you may then apply to SIRA for a review of the PIC’s decision.
Final steps
If you’re unsure whether your claim meets the criteria for an internal review, or if you need help preparing your evidence, contact a legal professional. Every claim depends on its own facts, and the Central Coast has specific legal nuances that may affect your case.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.