If your CTP claim is disputed by the insurer, understanding the internal review process is critical. In NSW, insurers must follow specific rules when reconsidering claims, and claimants have rights to challenge decisions before escalating to the Personal Injury Commission (PIC) or SIRA. This article explains what to expect during an insurer’s internal review, practical steps to take, and when to seek legal advice.
What is an Insurer’s Internal Review?
When an insurer rejects or limits a CTP claim, they must first conduct an internal review. This process allows them to reassess their decision based on new evidence, medical reports, or policy interpretations. Under NSW law, insurers cannot unreasonably delay this review. Claimants should request a written explanation of the insurer’s decision and ask for details on how the review will be conducted.
What Claimants Can Expect During an Internal Review
Insurers typically expect claimants to provide additional evidence to support their case. This may include:
- Updated medical records showing ongoing injuries
- Witness statements or accident reports
- Proof of income loss or care costs
Insurers may also request clarification on how injuries relate to the accident. For example, if a claimant is disputing a decision to limit weekly payments, they should provide medical evidence showing the injury meets the threshold injury definition under the Motor Accident Injuries Act 2017.
Practical Steps for Challenging an Insurer’s Decision
If the internal review does not resolve the dispute, claimants should:
- Request a written copy of the insurer’s decision and the reasons for it
- Gather evidence showing the insurer’s decision is incorrect or incomplete
- Seek independent medical advice if there is a disagreement about injury severity
Claimants should also note that insurers must provide a clear timeframe for completing the review. If they fail to act within reasonable timeframes, this could support a claim for procedural unfairness.
When to Escalate to the PIC or SIRA
If the insurer refuses to reconsider or provides an unsatisfactory response, claimants can escalate the matter to the PIC. The PIC will review the claim based on the Motor Accident Guidelines and may order the insurer to pay additional compensation. In complex cases, the State Insurance Regulatory Authority (SIRA) can also intervene to ensure compliance with CTP rules.
Example: Disputing a Weekly Payment Reduction
Consider a claimant who received weekly payments for a soft tissue injury but is told their payments will stop after 52 weeks. The insurer may argue the injury is a 'threshold injury' under the Motor Accident Injuries Act 2017. The claimant should provide medical evidence showing the injury meets the spinal nerve-root qualification or has resulted in long-term impairment. This demonstrates why weekly payments should continue beyond the 52-week period.
Time Limits and Dispute Resolution
Insurers must act within 28 days of receiving a claimant’s request for an internal review. If they fail to respond within this timeframe, the claimant may have grounds to challenge the insurer’s failure to comply with procedural rules. Claimants should also be aware that disputes can take several months to resolve, especially if medical evidence is required.
Final Steps for Claimants
If your CTP claim is disputed, take these actions:
- Write to the insurer requesting a detailed explanation of their decision
- Gather all relevant evidence, including medical records and accident reports
- Seek independent advice if you disagree with the insurer’s interpretation of your injuries
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.