Understanding Insurer Internal Reviews in NSW
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 Compulsory Third Party (CTP) claim has been denied, you may be eligible to request an internal review before escalating to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). This process allows insurers to reconsider their decision based on new evidence or interpretation of policy terms. Understanding how to challenge a denied CTP claim is critical for injured road users in NSW, particularly in areas like Bankstown where claims are frequently contested.
NSW CTP Rules Behind Insurer Internal Reviews
Under NSW law, insurers must provide a written explanation for denying a CTP claim. This includes outlining the reasons for the decision and referencing the relevant sections of the Motor Accident Injuries Act 2017. If you believe the decision is incorrect, you can request an internal review by submitting a formal written objection to the insurer within 28 days of receiving the denial notice. This timeframe is strictly enforced, and missing it may prevent you from escalating the matter further.
The insurer’s internal review process typically involves a reassessment of the claim based on the evidence provided. This may include re-evaluating medical reports, accident details, and the insurer’s interpretation of policy terms.
Practical Steps to Challenge a Denied CTP Claim
To request an internal review, you must submit a written objection to the insurer. This should clearly state your disagreement with the decision and reference the specific policy terms or legal provisions you believe were misinterpreted. Include any new evidence that supports your claim, such as additional medical records, witness statements, or accident reports.
For example, if the insurer denied your claim based on a threshold injury assessment, you may need to provide updated medical evidence showing that your injury meets the criteria outlined in the Motor Accident Guidelines. It is also essential to document the insurer’s response to the review, as this may be required if you need to escalate the matter to the PIC or SIRA.
Time Limits and Dispute Options
You have 28 days from the date of the denial notice to request an internal review. If the insurer does not respond within this timeframe or refuses to reconsider the claim, you may need to escalate the matter to the PIC or SIRA.
If the insurer’s decision is upheld, you may still have options to challenge the claim further. For instance, if the denial is based on a medical assessment, you may seek a second opinion from a medical practitioner accredited by SIRA. This can be a key step in demonstrating that the insurer’s interpretation of your injury is incorrect.
SIRA’s Role in Regulating Insurer Reviews
SIRA oversees the CTP insurance industry in NSW and ensures that insurers comply with the Motor Accident Injuries Act 2017. If an insurer fails to conduct a proper internal review or refuses to reconsider a claim, SIRA may intervene. However, SIRA does not typically review claims unless there is a clear breach of the Act or regulatory requirements.
It is also important to understand that SIRA’s role is not to make decisions on individual claims but to ensure that insurers follow the correct procedures. If your claim is denied and you believe the insurer has acted unfairly, you may need to seek independent legal advice to explore further options.
When to Seek Legal Advice
While the internal review process provides an opportunity to challenge a denied CTP claim, it is not guaranteed to result in a change of decision. If the insurer upholds the denial, you may need to consider other options, such as disputing the claim through the PIC or seeking a legal review of the insurer’s decision.
In some cases, it may be necessary to consult a solicitor who specialises in CTP claims to assess whether there are additional legal grounds for challenging the denial. A legal professional can also help you navigate the process of escalating the matter to the PIC or SIRA and ensure that all procedural requirements are met.
Conclusion
Understanding the insurer’s internal review process is essential for anyone who has had their CTP claim denied in NSW. By following the correct steps, providing the necessary evidence, and acting within the required time limits, you may be able to challenge the decision and secure the compensation you deserve. However, it is important to remember that each claim is unique, and the outcome may depend on the specific circumstances of your case. For further assistance, complete the quick, no obligation enquiry form to request contact about your circumstances.