Understanding Insurer Internal Reviews in NSW CTP Claims
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).
If you are disputing a decision made by your insurer regarding a motor accident claim in the Illawarra or South Coast region of New South Wales, you may be required to first request an internal review. The Personal Injury Commission (PIC) expects claimants to exhaust internal review processes before escalating a dispute to the PIC or the State Insurance Regulatory Authority (SIRA). This step is not optional under the Motor Accident Injuries Act 2017 and must be followed to maintain eligibility for formal dispute resolution.
The PIC does not automatically accept claims for review unless the insurer has already issued a formal decision and the claimant has formally requested a reconsideration internally. This process ensures that insurers have a reasonable opportunity to reassess their position before external review. The expectation is that claimants provide all relevant evidence and documentation to support their request, including medical reports, treatment records, and correspondence with the insurer.
What the PIC Expects During Internal Reviews
The PIC expects claimants to demonstrate that they have made a genuine effort to resolve the dispute with the insurer before seeking external review. This includes:
- Submitting a written request for internal review within a reasonable timeframe after receiving the insurer’s decision.
- Providing a clear statement of the grounds for dispute, such as disagreement with the assessment of injury severity, denial of treatment and care benefits, or rejection of weekly income payments.
- Including all supporting evidence, particularly medical evidence that confirms the nature and impact of the injury, such as MRI reports, neurologist assessments, or functional capacity evaluations.
The PIC notes that internal reviews are not a formality. Insurers are required to reconsider decisions based on new or additional evidence. However, if the insurer maintains its original decision, the claimant may then apply to the PIC for review. The PIC will not accept a claim for review if the internal review process was not properly initiated or if the claimant failed to provide sufficient grounds for reconsideration.
Practical Steps for Claimants in Illawarra and South Coast
Claimants in the Illawarra and South Coast regions should follow these steps when disputing an insurer’s decision:
- Obtain a copy of the insurer’s written decision, including any reasons for denial or reduction of benefits.
- Gather all relevant evidence, including medical reports, treatment logs, photographs of the accident scene, and any correspondence with the insurer.
- Submit a formal internal review request to the insurer, clearly stating the grounds for dispute and attaching all supporting documentation.
- Allow the insurer a reasonable period to respond, typically 21 days, though this may vary depending on the insurer’s internal policy.
- If the insurer upholds its original decision, you may then apply to the PIC for review.
The PIC has published guidance on how to prepare a dispute application, including a checklist of required documents. Claimants in regional areas like the Illawarra and South Coast may find it helpful to contact the SIRA Claims Information Line for assistance in understanding the process and ensuring all documentation is complete.
Time Limits and Procedural Requirements
Time limits apply to internal review requests and subsequent applications to the PIC. Under the Motor Accident Injuries Act 2017, a claimant must apply to the PIC within 12 months of the insurer’s final decision. This deadline is strict and cannot be extended without a formal application to the PIC for extension, which is not guaranteed.
If you are seeking review of a medical assessment, such as a dispute over a whole person impairment (WPI) rating, the PIC expects that the claimant has obtained a second medical opinion and submitted it to the insurer as part of the internal review process. The PIC will not accept a dispute on medical grounds unless the claimant has provided a qualified medical report that contradicts the insurer’s assessment.
SIRA Resources for Regional Claimants
SIRA provides targeted support for claimants in regional NSW, including the Illawarra and South Coast. The SIRA website offers a range of tools, including:
- A step-by-step guide to making a motor accident claim, including dispute resolution pathways.
- A template for internal review requests, which can be adapted to your situation.
- A directory of local legal and financial advice services, including community legal centres that offer free initial advice.
Claimants in these regions are encouraged to use SIRA’s online resources and contact the SIRA Claims Information Line for assistance in navigating the dispute process. The PIC also offers a free dispute resolution support service for claimants who are not represented by a solicitor.
Hypothetical Example: Dispute Over Weekly Income Payments
A 38-year-old driver in Wollongong was injured in a motor vehicle accident in June 2024. The insurer denied weekly income payments on the basis that the claimant was not unable to work due to injury. The claimant provided a medical report from their treating doctor confirming a diagnosis of a soft-tissue injury with ongoing pain and reduced mobility. The claimant submitted a formal internal review request, including the medical report, a work capacity assessment, and a letter from their employer confirming reduced hours.
The insurer upheld its decision. The claimant then applied to the PIC for review, citing the new medical evidence and the employer’s statement. The PIC accepted the application and scheduled a review hearing. The claimant was represented by a community legal centre and received a favourable outcome, with weekly payments awarded from the date of the original claim.
When to Seek Independent Advice
While the PIC expects claimants to attempt internal review, it is not a substitute for legal advice. If the dispute involves complex medical issues, a claim for damages, or a dispute over a threshold injury, it is advisable to seek independent legal advice before initiating the internal review process.
The PIC does not provide legal representation. It only reviews decisions made by insurers. If a claimant believes their rights under the Motor Accident Injuries Act 2017 have been breached, they may need to seek legal advice to determine whether a claim for damages or a review of a medical assessment is appropriate.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.