Understanding Dispute Resolution 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).
After a rear-end motor accident in New South Wales, an injured person may face disputes with their insurer over liability, injury assessment, or the amount of compensation they are entitled to. Dispute resolution options under the NSW Compulsory Third Party (CTP) insurance scheme are governed by the Motor Accident Injuries Act 2017 and administered by the State Insurance Regulatory Authority (SIRA). These options allow claimants to seek resolution if they believe their insurer has made an incorrect decision regarding benefits, treatment, or entitlement to damages.
Key Dispute Resolution Pathways
The primary dispute resolution pathways available to claimants in NSW are:
- Internal review - The first step is to request a formal internal review of the insurer’s decision. This must be done within 28 days of receiving the decision, and the insurer must respond within 28 days. The review is conducted by a different team within the same insurer.
- SIRA’s dispute resolution process - If the internal review is unsatisfactory or not completed within the timeframe, the claimant may apply to SIRA for dispute resolution. SIRA provides a free, independent process to resolve disagreements about entitlements to treatment and care benefits, weekly income payments, or damages. The process is not binding on the insurer but often leads to a resolution.
- Personal Injury Commission (PIC) medical dispute pathway - Where the dispute concerns a medical assessment, such as a whole person impairment (WPI) rating, and the claimant disagrees with the independent medical examiner’s report, they may apply to the PIC for a medical dispute resolution. This process is separate from general dispute resolution and focuses on the medical evidence. The PIC will review the medical reports, assess the consistency with the Motor Accident Guidelines, and may order a new assessment.
Practical Steps and Evidence That Matter
To pursue dispute resolution effectively, claimants should gather and preserve the following evidence:
- A copy of the insurer’s written decision, including any reasons given.
- All medical records related to the accident, including initial assessments, treatment notes, imaging reports (X-rays, MRIs), and specialist reports.
- Documentation of lost income, such as payslips, employer letters, or tax returns.
- Photographs of the accident scene, vehicle damage, and any visible injuries.
- Witness contact details and statements, if available.
- A record of all communications with the insurer, including emails, letters, and call logs.
Time Limits and Procedural Requirements
Time limits are critical in dispute resolution. An internal review must be requested within 28 days of receiving the insurer’s decision. If not done within that period, the claimant may lose the right to challenge the decision through that route.
If applying to SIRA, the claim must be submitted within 12 months of the insurer’s decision. Failure to meet this deadline may prevent access to SIRA’s dispute resolution process.
The PIC medical dispute pathway must be initiated within 12 months of receiving the medical report in dispute. The PIC will not accept a medical dispute application if it has been more than 12 months since the report was issued.
How SIRA’s Process Differs from Other Options
SIRA’s dispute resolution process is distinct from informal negotiations or legal proceedings. It is a structured, free, and independent process that does not require a solicitor. SIRA assesses the claim based on the Motor Accident Injuries Act 2017, the Motor Accident Guidelines, and the evidence provided.
Unlike informal discussions, SIRA’s process results in a formal written determination. While not binding on the insurer, it carries significant weight and often leads to a resolution. If the insurer refuses to accept SIRA’s recommendation, the claimant may then consider a claim for damages in the NSW Supreme Court, but only if the injury meets the threshold for damages under the Act.
Hypothetical Example: Medical Dispute Over WPI Rating
A 42-year-old driver was involved in a rear-end collision in Sydney in March 2025. The claimant sustained a neck injury and was assessed by an independent medical examiner who assigned a WPI of 5%. The claimant believes this underestimates their ongoing pain and functional limitations. The claimant disputes the rating and applies to the PIC for a medical dispute resolution. The PIC reviews the medical evidence, including MRI results and a physiotherapist’s report, and determines that the WPI should be 10%. The insurer is not legally bound to accept this, but the revised rating strengthens the claimant’s position for future negotiations.
When to Seek Independent Advice
Dispute resolution is not a substitute for legal advice. The process can be complex, particularly when medical evidence is contested or when the claim involves a threshold injury. An injured person should consider seeking advice from a qualified legal practitioner if:
- The insurer refuses to accept a SIRA or PIC decision.
- The claim involves a dispute over liability or fault.
- The injury is a threshold injury and the claimant wishes to pursue damages.
- There are concerns about the accuracy of medical assessments or the insurer’s handling of the claim.
Final Considerations
The outcome of a dispute resolution process is not guaranteed. SIRA and the PIC do not have the power to force an insurer to change its decision. However, their determinations are based on law and medical standards and are often accepted by insurers.
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