Understanding Internal Reviews in NSW CTP Claims
When an insurer denies or reduces a claim under the Compulsory Third Party (CTP) scheme in New South Wales, the claimant has the right to request an internal review. This process allows the insurer to reconsider its decision based on new or additional information. In Greater Sydney and across NSW, common mistakes by insurers during internal reviews often stem from misapplying the Motor Accident Injuries Act 2017 (MAIA), failing to properly assess medical evidence, or not adhering to SIRA’s procedural expectations. These errors can delay or prevent access to benefits such as treatment and care, weekly income payments, or damages.
Key Legal Frameworks Governing Internal Reviews
The Motor Accident Injuries Act 2017 (MAIA) and the Motor Accident Injuries Regulation 2017 form the basis of CTP claims in NSW. Under these laws, insurers must assess claims fairly and in good faith. SIRA’s guidance confirms that internal reviews must be conducted within a reasonable timeframe and must consider all relevant evidence, including medical reports, accident details, and financial documentation. Insurers are not permitted to rely solely on initial assessments without re-evaluating updated or newly submitted evidence.
Common Mistakes Insurers Make During Internal Reviews
Insurers frequently make errors that can undermine a claimant’s rights. These include:
- Failing to properly consider updated medical evidence, particularly where a claimant has undergone further assessment or treatment after the initial claim.
- Misapplying the threshold injury provisions under MAIA, particularly in cases involving soft tissue injuries with neurological signs. For example, an injury to a spinal nerve-root that causes sensory or motor deficits but not radiculopathy may still qualify as a threshold injury under the Motor Accident Guidelines.
- Not allowing claimants a reasonable opportunity to submit additional evidence before finalising a decision.
- Applying outdated or incorrect interpretations of the 52-week limit on statutory benefits, particularly where only threshold injuries are present and the claimant continues to experience ongoing consequences.
- Disregarding the principle that a claimant’s entitlement to treatment and care benefits does not automatically cease after 52 weeks if there is a continuing need, as long as the injury is not resolved.
How Claimants Can Respond to Flawed Internal Reviews
If an insurer’s internal review decision is based on one of these common errors, the claimant may challenge it. The first step is to formally request a review of the insurer’s decision, including a written explanation of why the review was not granted or why the outcome was unsatisfactory. The claimant should attach any new or previously unconsidered evidence, such as:
- A follow-up medical report from a specialist.
- A detailed statement from a treating practitioner outlining ongoing functional limitations.
- Photographs of the accident scene, vehicle damage, or injury manifestations.
- Records of lost income or reduced work capacity.
SIRA’s guidance confirms that claimants have the right to request a review of the insurer’s internal decision and to escalate to the Personal Injury Commission (PIC) if the review is not resolved.
Time Limits and Escalation Pathways
There is no fixed statutory deadline for requesting an internal review, but delays may affect the ability to pursue a claim later. If the insurer does not respond within a reasonable time, typically 28 days, claimants may proceed to the PIC. The PIC has authority to review both internal review decisions and insurer determinations, particularly where there is a dispute about medical evidence, entitlement to benefits, or the application of the threshold injury rules.
A claimant may also request a medical dispute resolution process through the PIC if the insurer disputes the medical evidence. This process allows for an independent medical assessment to resolve disagreements about the nature or severity of an injury.
Practical Steps to Avoid Being Disadvantaged
To avoid common pitfalls, claimants should:
- Preserve all correspondence with the insurer, including emails, letters, and call logs.
- Keep copies of medical reports, treatment records, and income documentation.
- Submit all evidence to the insurer at the earliest opportunity, ideally within 30 days of receiving a decision.
- Seek independent legal or claims advice before accepting a final decision, particularly if the claim involves a threshold injury, ongoing treatment, or a dispute about impairment.
Hypothetical Example: A Claimant’s Experience in Sydney
A 42-year-old office worker in Sydney was involved in a rear-end collision in a car park in June 2024. The insurer initially accepted liability but denied weekly payments on the grounds that the claimant’s neck injury was a minor soft tissue injury, not a threshold injury. After the claimant underwent a second medical assessment showing a spinal nerve-root injury with confirmed sensory loss, the insurer conducted an internal review but failed to consider the new evidence. The claimant challenged the decision by submitting the updated report and requesting a review. The insurer upheld its original decision, citing a lack of radiculopathy. The claimant then escalated to the PIC, which referred the matter to a medical dispute resolution process. The independent assessment confirmed a threshold injury, and the claimant was awarded weekly payments and treatment and care benefits.
Next Steps and When to Seek Advice
Every claim depends on its own facts. Insurers are not required to accept a claimant’s interpretation of medical evidence, but they must assess it fairly and in line with SIRA’s guidelines. If an insurer’s internal review decision appears flawed, particularly in how it interprets medical evidence, applies the threshold injury rules, or handles ongoing treatment needs, claimants have the right to challenge it.
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