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 in rural or remote NSW and your CTP insurer has denied or limited your claim, understanding their internal review process is critical. This article explains how insurers assess disputed claims, how to challenge decisions using SIRA guidelines, and the unique challenges faced by rural claimants. Time limits, evidence requirements, and when to seek legal advice are also covered.
NSW CTP Insurer Internal Review Process
Under the Motor Accident Injuries Act 2017, CTP insurers must review claims before making final decisions. This process typically involves:
- Initial assessment: Insurers evaluate medical records, accident reports, and evidence of injury.
- Internal review: If a claim is disputed, the insurer must reconsider it within 28 days of receiving new information (s 4.4). This includes reassessing medical opinions and claimant evidence.
- Medical dispute pathway: If a claimant disputes the insurer's medical assessment, they can request a review by the Personal Injury Commission (PIC) under s 4.5. Rural claimants may face delays due to limited access to PIC services.
Insurers cannot refuse to review a claim solely because it was submitted by a solicitor or because the claimant lives in a remote area. However, claimants must act within strict time limits.
Challenging an Insurer's Decision in Rural NSW
Claimants in rural areas face unique barriers, including limited access to legal services and delays in accessing PIC medical reviews. To challenge a decision:
1. Request an internal review
If your claim was denied or limited, you must ask the insurer to review its decision within 28 days of receiving new information. This can include:
- Updated medical reports
- Witness statements
- Accident reconstruction evidence
Insurers must provide a written explanation of their decision, including the medical reasoning used.
2. Use the PIC medical dispute pathway
If the insurer's medical assessment is disputed, claimants can request a review by the Personal Injury Commission. This process involves:
- Submitting a formal request to the PIC
- Providing medical records and expert opinions
- Waiting for a medical review (which may take longer in rural areas)
The PIC's decision is binding unless appealed to the NSW Civil and Administrative Tribunal (NCAT).
3. Seek legal assistance
In rural areas, claimants may need to use video conferencing or postal services to access legal advice. Solicitors in regional NSW often specialise in CTP disputes and can help with:
- Preparing dispute submissions
- Navigating PIC medical reviews
- Applying for urgent review orders
Practical Steps and Evidence That Matter
To challenge an insurer's decision, claimants must gather:
- Medical evidence: Detailed records showing injury, treatment, and ongoing effects. This includes GP notes, specialist reports, and imaging.
- Accident details: Police reports, witness statements, and photos of the scene.
- Income records: Proof of lost wages or reduced earning capacity.
- Insurer correspondence: All communications with the insurer, including dates and decision reasons.
Insurers often dispute claims based on incomplete or delayed evidence. For example, if a claimant only provides a GP note without specialist confirmation, the insurer may reject the claim.
Time Limits and When to Seek Advice
Key deadlines include:
- 28 days to request an internal review after new information is received.
- 28 days to apply for a PIC medical review after the insurer's decision.
- 28 days to file an NCAT application if the PIC decision is unsatisfactory.
Rural claimants may face additional delays due to limited access to legal services. Seeking advice early is crucial, as insurers may close claims if the time limit is missed.
Hypothetical Example: Rural Claimant Challenges Denial
A farmer in Dubbo was injured in a car accident and submitted a claim. The insurer denied the claim, arguing there was no 'threshold injury.' The claimant:
- Requested an internal review, providing a specialist report showing soft-tissue injury.
- Applied for a PIC medical review, which confirmed the injury met the threshold.
- Used a regional solicitor to challenge the insurer's decision.
The insurer eventually agreed to pay weekly benefits after the PIC's review. This example shows how rural claimants can overcome insurer denials with proper evidence and legal support.
Next Steps for Rural Claimants
If your insurer has denied or limited your claim, act quickly. Start by requesting an internal review and gathering all relevant evidence. If the insurer's decision is unsatisfactory, contact a solicitor in your area to explore options like a PIC medical review or NCAT application. Rural claimants may need to use alternative methods like video consultations to access legal advice.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.