Common Mistakes in Insurer Internal Reviews
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).
Insurer internal reviews of NSW Compulsory Third Party (CTP) claims often lead to disputes over compensation decisions. Claimants in Illawarra and South Coast must avoid specific errors to ensure their case is properly assessed. One major mistake is failing to follow the correct review process outlined in SIRA guidelines. Insurers typically require claimants to submit a formal written request for reconsideration before escalating disputes to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). Not adhering to this step can delay or derail the review.
Another frequent error is submitting incomplete or unclear evidence. SIRA’s guidelines emphasize the importance of providing detailed medical records, accident reports, and witness statements to support claims. Claimants who omit key documentation, such as a doctor’s report confirming a threshold injury, risk having their claim dismissed or undervalued.
Time Limits and Dispute Pathways
NSW CTP claims have strict time limits. For example, weekly income payments and treatment benefits are generally limited to 52 weeks if the injury is classified as a threshold injury under the Motor Accident Injuries Act 2017. Claimants must act quickly to challenge decisions before these deadlines expire. Delays in disputing an insurer’s assessment can result in lost entitlements.
If an insurer refuses to reconsider a claim, claimants can escalate the matter to the PIC or SIRA. However, this process requires careful adherence to procedural rules. For instance, claimants must first exhaust the insurer’s internal review before seeking external review. Failing to follow this order can lead to unnecessary delays or rejection of the claim.
Practical Steps to Avoid Errors
To avoid mistakes during internal reviews, claimants should:
- Submit a formal written request for reconsideration, clearly outlining why the decision should be reviewed.
- Provide all relevant evidence, including medical records, accident details, and income records.
- Seek advice from a solicitor or SIRA’s free assistance services if unsure about the process.
SIRA’s guidelines also highlight the importance of accurate medical assessments. If a claimant’s injury is classified as a threshold injury, they must ensure that the medical evidence meets the specific criteria outlined in the Motor Accident Guidelines. Misclassifying an injury can lead to incorrect benefit calculations.
When to Seek Legal Advice
Claimants should consult a solicitor if they face repeated rejections, are unsure about their entitlements, or need help navigating the dispute process. Legal professionals can help identify errors in claims, challenge incorrect classifications of injuries, and ensure compliance with time limits.
Example of a Common Error
A claimant in the Illawarra region once missed a key deadline by failing to submit a medical report confirming a threshold injury within 52 weeks. The insurer correctly limited benefits after this period, leaving the claimant without full compensation. This highlights the importance of acting promptly and providing complete evidence.
Next Steps
CTP claims depend on accurate information, timely action, and adherence to procedural rules. To avoid errors during insurer internal reviews, claimants should carefully follow SIRA guidelines and seek legal advice when needed. For personalized assistance, complete the quick, no obligation enquiry form to request contact about your circumstances.