Understanding Insurer Internal Reviews in NSW CTP Claims
When a motor accident occurs in New South Wales, the insurer of the at-fault vehicle is responsible for assessing liability and determining entitlement to compensation under the Compulsory Third Party (CTP) insurance scheme. If an injured person disagrees with the insurer’s initial decision, such as a denial of liability, a refusal to pay benefits, or a dispute over injury severity, they may request an internal review. This process allows the insurer to reconsider its decision based on new or additional evidence. The Motor Accident Injuries Act 2017 (MAIA) and the Motor Accident Injuries Regulation 2017 set the framework for these reviews, which must be conducted in good faith and within a reasonable timeframe. Insurers are required to provide a written response to the internal review request, outlining the basis for their decision and any changes made.
How Insurers Assess Liability During Internal Reviews
Insurers assess liability based on the facts of the motor accident, including police reports, witness statements, photographs, and medical evidence. Under the MAIA, liability is determined by whether the driver of a vehicle failed to drive with reasonable care, as required by the Road Transport Act 2013. The insurer must consider whether the driver’s actions contributed to the accident, regardless of fault in a criminal sense. The assessment is not limited to a simple determination of who was at fault; it includes an evaluation of whether the injury was caused by the accident and whether the claimant’s injuries fall within the statutory thresholds for damages.
SIRA’s Motor Accident Claims guidelines provide practical direction on how insurers should interpret the law. For example, if a claimant has a soft tissue injury, the insurer must determine whether the injury meets the threshold for damages under the MAIA. This includes assessing whether there is evidence of a spinal nerve-root injury with neurological signs other than radiculopathy, as defined in the Motor Accident Guidelines. Insurers must not rely solely on medical reports without considering the full context of the accident and the claimant’s ongoing symptoms.
Practical Steps and Evidence That Matter
To strengthen a claim during an internal review, the claimant should provide clear and consistent evidence. This includes:
- A detailed account of the accident, including the time, location, weather, and road conditions.
- A copy of the police report, if one was filed.
- Photographs of the vehicles, damage, road markings, and any visible injuries.
- Witness contact details and written statements.
- Medical records from the treating practitioner, including diagnosis, treatment plan, and any functional limitations.
- A record of lost income, if applicable, supported by payslips or employer letters.
Insurers are required to consider all evidence submitted during the internal review. However, they are not obligated to accept new medical assessments unless they are from a qualified medical practitioner and supported by objective findings. The claimant should ensure that any medical evidence submitted is contemporaneous with the accident and includes a clear link between the injury and the motor accident.
Time Limits and Dispute Resolution Pathways
There is no fixed statutory deadline for an insurer to complete an internal review, but the process should be finalised within a reasonable timeframe, typically within 30 to 60 days. If the insurer does not respond within this period, or if the claimant remains dissatisfied with the outcome, they may escalate the matter to the Personal Injury Commission (PIC) or, in some cases, to the Supreme Court.
If the internal review results in a decision that denies or limits benefits, the claimant may apply to the PIC for a dispute resolution process. The PIC provides a formal pathway for resolving disputes over liability, injury classification, or benefit entitlements. In cases involving a medical dispute, such as disagreement over the nature or severity of an injury, the PIC may require an independent medical assessment under the MAIA.
The insurer may uphold its original decision based on the same evidence. However, the internal review process provides an opportunity to clarify misunderstandings and ensure that all relevant information has been considered.
When to Seek Independent Advice
The process of challenging an insurer’s decision can be complex, particularly when medical evidence, liability, or statutory thresholds are in dispute. The Motor Accident Injuries Act 2017 and SIRA’s guidelines are not always straightforward to interpret without legal or medical expertise. For example, the distinction between a threshold injury and a non-threshold injury can significantly affect entitlement to damages, and the presence of a spinal nerve-root injury with neurological signs may still qualify as a soft-tissue injury under the Motor Accident Guidelines.
A hypothetical example: A pedestrian was struck by a car in a residential area. The insurer initially denied liability, citing a lack of witness evidence and a police report that did not assign fault. The claimant submitted a medical report confirming a brachial plexus injury with neurological signs, supported by MRI findings. After an internal review, the insurer accepted liability and agreed to pay treatment and care benefits. This outcome was achieved because the claimant provided objective medical evidence that met the statutory definition of a threshold injury.
Next Steps
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