Navigating Insurer Internal Reviews and Medical Assessments in NSW
If your motor accident claim in Bankstown is under review by your insurer, and a medical assessment is being arranged, you are in a critical phase of your CTP claim. Insurers may initiate internal reviews to reassess your entitlement to benefits, including treatment and care, weekly income payments, or damages. These reviews often precede a formal dispute with the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). Preparing effectively for medical assessments during this process is essential to ensure your injuries and impacts are properly recognised under the Motor Accident Injuries Act 2017.
The Legal Framework for Internal Reviews and Medical Assessments
Under the Motor Accident Injuries Act 2017, insurers are required to assess claims based on medical evidence, including assessments conducted by independent medical practitioners. An internal review is not a final decision but a process where the insurer reconsiders its initial determination. This may occur if new medical information emerges, or if the insurer believes the original assessment was incorrect. The review must be conducted in accordance with SIRA’s Motor Accident Guidelines, which set standards for medical evidence and assessment procedures.
Medical assessments during an internal review are typically arranged to confirm or clarify the nature, severity, and impact of your injuries. These assessments may be conducted by a specialist, such as a neurologist, orthopaedic surgeon, or rehabilitation physician, depending on your injury. The insurer must provide you with written notice of the assessment, including the date, time, location, and purpose. You have the right to attend the assessment and to bring a support person.
Key Steps to Prepare for a Medical Assessment
To ensure your medical assessment is fair and comprehensive, follow these practical steps:
- Obtain a copy of your medical records from your treating medical practitioner, including reports, imaging results, and treatment notes. These records should cover the period from the accident to the present.
- Provide the insurer with a written summary of your ongoing symptoms, functional limitations, and impact on daily life. This helps the assessor understand your experience beyond clinical findings.
- Bring any relevant documentation to the assessment, including a diary of symptoms, photographs of visible injuries, and records of lost work or household duties.
- If you have a support person, arrange for them to attend the assessment to help you explain your condition and to observe the process.
- Do not alter or fabricate any medical information. The insurer and SIRA may verify the accuracy of your records.
SIRA advises that medical assessments must be conducted in a way that is fair, transparent, and free from bias. You have the right to request a copy of the assessor’s report before it is submitted to the insurer.
Common Mistakes to Avoid
Claimants often make errors that can undermine their claim during an internal review. These include:
- Failing to notify the insurer of new or worsening symptoms after the initial claim was made.
- Not attending a scheduled medical assessment without valid reason, which may result in a delay or suspension of benefits.
- Providing inconsistent information to different medical practitioners, which can raise concerns about credibility.
- Assuming that a negative assessment outcome means your claim will be denied. A negative report may be challenged through a formal dispute process.
It is also a common error to believe that internal reviews are final. They are not. An insurer’s internal review decision may be challenged through the PIC or SIRA, particularly if you believe the medical assessment was incomplete or inaccurate.
Dispute Pathways and Time Limits
If you disagree with the outcome of an internal review, you may escalate the matter to the Personal Injury Commission (PIC). The PIC is the independent body that handles disputes over CTP claims in NSW. You must apply to the PIC within 12 months of the insurer’s internal review decision, or within 12 months of the date the insurer first refused to pay a benefit, whichever is later. This time limit is strict and cannot be extended unless exceptional circumstances apply.
The PIC will consider all evidence, including the medical assessment report, your treatment records, and any written submissions you provide. You may request a review of the assessment process if you believe the assessor did not follow SIRA’s guidelines, or if the assessment was not conducted in a timely manner.
It is important to understand that challenging a medical assessment does not guarantee a change in the insurer’s decision. The PIC may uphold the original assessment, or it may order a new assessment. The process can take several months, and you may need to attend another assessment.
When to Seek Independent Advice
Given the complexity of medical evidence and insurer procedures, it is advisable to seek independent legal or claims advice before attending a medical assessment during an internal review. A qualified professional can help you understand your rights, review the medical assessment request, and prepare you for the process.
For residents in Bankstown, local legal practitioners and claims support services are available to assist with CTP claims. They can help you gather evidence, respond to insurer correspondence, and represent you in any dispute. However, you are not required to have a lawyer to make a claim or respond to an internal review.
A Realistic Example
A 42-year-old cyclist in Bankstown was involved in a motor vehicle accident in June 2025. The insurer initially approved treatment and care benefits. In December 2025, the insurer issued an internal review, citing a medical assessment that found no significant long-term impairment. The claimant, who continues to experience chronic neck pain and reduced mobility, sought advice. With help from a claims adviser, they submitted updated medical records, a symptom diary, and a letter from their physiotherapist. The insurer later revised its decision after reviewing the new evidence, and the claimant was granted ongoing treatment and care benefits.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.