What the PIC Expects During an Insurer's Internal Review
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
If your Compulsory Third Party (CTP) claim is under review by the insurer, understanding the Personal Injury Commission's (PIC) expectations is critical. Insurers in NSW, including those in Armidale, must follow strict guidelines when reconsidering claims. The PIC expects claimants to provide clear evidence supporting their case, including medical records, accident details, and any documentation of injuries. This process is governed by the Motor Accident Injuries Act 2017 and SIRA’s dispute resolution protocols.
Key Steps for Claimants During an Internal Review
When an insurer initiates an internal review, claimants should:
- Respond promptly to the insurer’s request for additional information.
- Submit all relevant evidence, such as medical reports, accident reports, and witness statements.
- Clarify any ambiguities in the claim, such as the nature of injuries or the impact on daily life.
The PIC expects claimants to address the insurer’s concerns directly. For example, if the insurer disputes the severity of injuries, medical evidence from a registered medical practitioner must be provided to support the claim.
Evidence the PIC Prioritizes in Disputes
SIRA’s guidance emphasizes that evidence must be clear, contemporaneous, and directly related to the claim. Key documents include:
- Medical records showing the injury’s impact (e.g., treatment plans, recovery timelines).
- Accident reports from the NSW Police or traffic authorities.
- Witness statements confirming the incident’s circumstances.
- Income records if the injury has affected earning capacity.
In disputes, the PIC will assess whether the evidence meets the threshold injury criteria under the Motor Accident Guidelines. For instance, soft tissue injuries must demonstrate neurological signs, as outlined in the guidelines.
Time Limits and When to Seek Advice
Insurers must act within 52 weeks of the accident for claims involving threshold injuries. If the review extends beyond this period, the PIC may limit benefits. Claimants should seek legal advice if:
- The insurer refuses to reconsider the claim.
- The review process exceeds 52 weeks.
- There is a dispute over the type of injury or its impact.
In Armidale, claimants can contact SIRA directly or consult a solicitor to challenge the insurer’s decision. The PIC’s dispute resolution pathway ensures that claimants have a formal process to contest decisions.
A Hypothetical Example
Consider a claimant who suffered a soft tissue injury in a car accident. The insurer disputes the injury’s severity, citing no radiculopathy. The PIC expects the claimant to provide medical evidence showing neurological signs, such as reduced reflexes or sensory loss, as required by the Motor Accident Guidelines. Without such evidence, the claim may be denied or limited.
Next Steps
CTP claims depend on the accident date, injury type, and evidence quality. If you’re in Armidale and facing an insurer’s internal review, it’s essential to act quickly and seek professional guidance. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.