How SIRA Guides Insurer Internal Reviews for NSW CTP Claims Disputes
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 your insurer has denied or reduced your NSW Compulsory Third Party (CTP) claim, you may need to request an internal review before escalating the dispute. The State Insurance Regulatory Authority (SIRA) provides clear rules on how insurers must handle such reviews. This article explains SIRA’s guidelines, how to challenge insurer decisions, and when to seek further action.
What SIRA Rules Apply to Insurer Internal Reviews?
SIRA’s guidelines state insurers must review claims decisions within 28 days of receiving new evidence or a formal request. Insurers must provide written reasons for their decisions and explain how they applied the Motor Accident Injuries Act 2017 (MAIA) and Motor Accident Guidelines. For example, if an insurer rejects a claim for soft-tissue injuries, they must detail why the injury does not meet the threshold injury definition under the guidelines.
How to Challenge an Insurer’s Decision
Claimants can request an internal review by writing to the insurer, clearly stating the grounds for reconsideration. This includes disputing the assessment of injuries, benefits, or time limits. SIRA requires insurers to consider all relevant evidence, such as medical records, accident reports, and witness statements. If the insurer refuses to review or provides unsatisfactory reasons, you may escalate the matter to the Personal Injury Commission (PIC) or SIRA.
Key SIRA Rules for Disputes
- Time Limits: Insurers must respond to internal review requests within 28 days. If they fail to act within this timeframe, the claimant may have grounds to challenge the delay.
- Medical Evidence: SIRA emphasizes that insurers must base decisions on medical evidence. If an insurer disputes a claim without considering a doctor’s report, you can argue they violated SIRA’s rules.
- Escalation Pathways: If an internal review is unsatisfactory, claimants can apply to the PIC for a medical dispute review. SIRA also has a complaints process for insurers that fail to follow their guidelines.
Practical Steps for Claimants
- Request a written review: Ask the insurer to provide detailed reasons for their decision.
- Gather evidence: Ensure medical records, accident reports, and witness statements are complete.
- Check time limits: Act within 28 days of receiving the insurer’s decision to request a review.
- Escalate if needed: Contact SIRA or the PIC if the insurer ignores your request or misapplies the rules.
When to Seek Legal Advice
If your insurer refuses to review your claim, ignores SIRA’s rules, or disputes your entitlement to benefits, it may be time to consult a solicitor. Legal advice can help you challenge the insurer’s decision through formal dispute processes or apply to the PIC for a medical review.
Example Scenario
Imagine a claimant who suffered a soft-tissue injury in a car accident. The insurer denies the claim, arguing it does not meet the threshold injury definition. The claimant requests an internal review, but the insurer refuses to reconsider. Under SIRA’s rules, the claimant can escalate the matter to the PIC, where a medical expert may reassess the injury’s severity.
Next Steps
CTP claims depend on the accident date, injury type, and insurer actions. If you’re unsure how SIRA’s rules apply to your case, complete the quick, no obligation enquiry form to request contact about your circumstances.