Understanding Insurer Internal Reviews in NSW 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 motor accident claim has been declined or limited by an insurer, you have the right to request an internal review. This process allows the insurer to reconsider their decision based on new or additional evidence. In New South Wales, this internal review is governed by the Motor Accident Injuries Act 2017 and administered under the framework provided by the State Insurance Regulatory Authority (SIRA). The review is not a formal legal hearing, but a procedural step within the insurer’s own claims handling process. It is available to claimants who believe the insurer’s decision, whether regarding treatment and care benefits, weekly income payments, or eligibility for damages, is incorrect or not supported by the evidence.
What Factors Insurers Consider in an Internal Review
Insurers assess internal review requests based on the evidence provided and the legal requirements under the Motor Accident Injuries Act 2017. Key factors include:
- The nature and severity of injuries, particularly whether they meet the threshold for damages under the Act
- Medical evidence showing a causal link between the accident and the injury
- The timing and completeness of treatment and care records
- Whether the claimant has met the 52-week statutory benefit period, which limits ongoing treatment and care benefits if only threshold injuries are present
- Whether the claimant has provided all relevant documentation, including accident reports, witness statements, and income records
Insurers are not required to change their decision simply because a review is requested. Their determination must be based on the law and the evidence available at the time of the original decision. However, new medical reports, updated assessments, or previously overlooked documentation may prompt a reconsideration.
How SIRA’s Approach Differs from Internal Insurer Reviews
SIRA’s role is distinct from an insurer’s internal review. While an internal review is conducted by the insurer, SIRA provides independent oversight and guidance on claim processing. SIRA’s Motor Accident Claims guidelines outline how insurers should assess claims and determine entitlements. These guidelines are not binding on insurers but are used as a benchmark for compliance.
If an internal review is unsuccessful, the claimant may apply to the Personal Injury Commission (PIC) for a review of the insurer’s decision. The PIC is an independent body that can assess whether the insurer’s decision was reasonable under the law. Unlike an internal review, a PIC review is a formal process that may result in a binding determination. The PIC will consider whether the insurer applied the correct legal principles, including the threshold injury provisions and the 52-week rule for statutory benefits.
Time Limits for Requesting an Internal Review
There is no fixed statutory time limit for requesting an internal review under the Motor Accident Injuries Act 2017. However, it is strongly advised to submit your request as soon as possible after receiving the insurer’s decision. Delaying may affect the insurer’s ability to verify evidence, particularly medical records or witness statements.
If you are seeking to challenge a decision regarding weekly income payments or treatment and care benefits, it is essential to act promptly. The 52-week period for statutory benefits begins from the date of the accident and may impact your entitlements if you are relying on only threshold injuries. Any delay in seeking review may also affect your ability to access the PIC, which has a 12-month time limit from the date of the insurer’s final decision.
Practical Steps and Evidence to Support Your Review
To strengthen your internal review request, gather and submit the following evidence:
- A copy of the insurer’s written decision, including any reasons provided
- Updated medical reports from your treating practitioner, including assessments of whole person impairment (WPI) and functional capacity
- A detailed record of all treatment received since the accident, including dates, types of treatment, and outcomes
- Photographs of the accident scene, vehicle damage, or injury symptoms
- Witness statements, if available, confirming the circumstances of the accident
- Pay slips or tax returns showing loss of income
- Correspondence with the insurer, including emails and letters
Include a clear statement explaining why you believe the insurer’s decision was incorrect. For example, if your claim for weekly income payments was denied, explain how your injury has prevented you from returning to work and provide evidence of your pre-accident earnings.
Hypothetical Example: Challenging a Denial of Weekly Payments
A 38-year-old office worker in Sydney’s inner west was involved in a rear-end collision in a car park. The insurer denied weekly income payments on the grounds that she had not provided sufficient evidence of loss of earnings and that her injuries were not severe enough to justify a claim. She submitted a new medical report from her specialist confirming ongoing neck and back pain, a WPI of 10%, and a recommendation for modified duties. She also provided a letter from her employer confirming she had been unable to return to her full duties for 14 weeks. The insurer reviewed the new evidence and subsequently approved her claim for 26 weeks of weekly payments.
When to Seek Independent Legal Advice
An internal review does not guarantee a change in the insurer’s decision. The insurer has discretion in how they assess claims, but they must act reasonably and in accordance with the law. If your review is unsuccessful, or if you believe the insurer has not properly considered the evidence, you may wish to seek independent legal advice before escalating to the Personal Injury Commission.
Legal advice can help you understand whether your claim meets the threshold for damages, whether the 52-week rule applies, and whether you have a valid basis for a PIC review. It can also assist in preparing a formal application and ensuring all procedural requirements are met.
Next Steps: Requesting Contact About Your Claim
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.