What the PIC Expects 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).
When a claimant disputes a decision by an insurer in a New South Wales Compulsory Third Party (CTP) motor accident claim, the insurer must conduct an internal review before escalating the matter to the Personal Injury Commission (PIC). The PIC expects insurers to follow strict guidelines to ensure fairness and compliance with the Motor Accident Injuries Act 2017 (MAIA) and SIRA's Motor Accident Claims Guidelines. Understanding what the PIC expects during these reviews is critical for claimants seeking resolution.
Key Legal Framework for Insurer Reviews
- Under NSW law, insurers must first assess claims based on the
- Motor Accident Injuries Act 2017* and the
- Motor Accident Injuries Regulation 2017*. The PIC oversees disputes where insurers fail to resolve claims internally. SIRA's guidelines outline that insurers must consider all relevant evidence, including medical records, accident reports, and witness statements, before making a decision. If a claimant disputes the insurer's decision, the insurer must provide a written explanation of its reasoning and offer an opportunity to submit additional evidence.
Practical Steps for Claimants During Disputes
If your CTP claim is disputed, take the following steps:
- Request a written explanation of the insurer's decision, including the specific reasons for the denial or adjustment.
- Submit additional evidence such as updated medical records, accident reports, or witness statements.
- Follow up in writing if the insurer delays or refuses to reconsider the claim.
Insurers are required to respond to disputes within 28 days under the MAIA. If they fail to act within this timeframe, the claimant may escalate the matter to the PIC.
Evidence That Matters in Internal Reviews
Insurers rely on specific evidence to assess claims. Key documents include:
- Medical records confirming the injury's nature and treatment.
- Accident reports from police or witnesses.
- Photographs of the accident scene or vehicle damage.
- Income records to support claims for lost wages.
- Correspondence with the insurer showing the claimant's efforts to resolve the dispute.
The PIC expects insurers to evaluate all this evidence objectively. If an insurer denies a claim without a clear justification, the claimant may have grounds to challenge the decision.
Time Limits and When to Seek Advice
Insurers must resolve disputes within 28 days of receiving a claimant's request for reconsideration. If they fail to act within this period, the claimant may apply to the PIC for a review. Under the MAIA, claimants must also file a dispute with the PIC within 28 days of the insurer's final decision.
If the insurer's internal review is unsatisfactory, the claimant should seek legal advice promptly. A solicitor can help prepare a formal dispute with the PIC, ensuring all evidence is presented correctly.
Example of a PIC Dispute Scenario
Consider a claimant who suffered a soft-tissue injury in a car accident. The insurer denies the claim, arguing the injury does not meet the 'threshold injury' definition under the MAIA. The claimant submits medical records showing neurological signs, which the insurer ignores. The PIC may then review the case, requiring the insurer to justify its reliance on outdated guidelines.
Next Steps for Claimants
If your CTP claim is disputed, document all interactions with the insurer and ensure your evidence meets the PIC's standards. Time limits are strict, so act quickly to protect your rights. For personalized advice, complete the quick, no obligation enquiry form to request contact about your circumstances.
Why Legal Advice Matters
While the PIC provides a pathway for resolving disputes, the process can be complex. A solicitor can help you:
- Navigate the PIC's medical dispute pathway.
- Challenge an insurer's reliance on outdated or incorrect SIRA guidelines.
- Prepare a strong case for review.
Do not assume the PIC will automatically overturn an insurer's decision. A legal professional can help you present your case effectively.
Final Considerations
Insurer internal reviews are a critical step in resolving CTP disputes. The PIC expects insurers to act fairly and transparently, but claimants must take proactive steps to protect their rights. If you are unsure how to proceed, seek legal advice before deadlines expire.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.