Understanding SIRA Complaints About Insurers and Medical Assessments
If you are involved in a motor accident in the Newcastle or Hunter region and believe your insurer is improperly preparing for a medical assessment, you may have grounds to raise a complaint with the State Insurance Regulatory Authority (SIRA). SIRA is the NSW government body responsible for overseeing the Compulsory Third Party (CTP) insurance scheme. Complaints about insurer conduct, including how they manage medical assessments, are handled under SIRA’s formal process. This includes situations where an insurer delays, mismanages, or fails to properly arrange assessments that are critical to determining your entitlement to benefits.
The Legal Framework for Medical Assessments in NSW CTP Claims
Under the Motor Accident Injuries Act 2017, medical assessments are a formal part of the CTP claims process. These assessments are conducted by independent medical practitioners to determine the nature, extent, and impact of injuries sustained in a motor accident. Insurers are required to arrange assessments in a timely and fair manner, and must provide claimants with clear information about the process, including the purpose, timing, and location.
Insurers must also follow the Motor Accident Injuries (Medical Assessment) Regulation 2017, which sets out procedural standards for assessments. These include ensuring the medical practitioner is qualified and independent, and that the claimant is given adequate notice and opportunity to prepare. Insurers must not use assessments to delay or deny benefits without proper justification.
What to Do If You Dispute an Insurer’s Preparation of a Medical Assessment
If you believe your insurer is not properly preparing for a medical assessment, such as failing to provide sufficient notice, not arranging an appropriate medical practitioner, or using the assessment to challenge your claim unfairly, you can take several steps.
First, document all communications with the insurer, including emails, letters, and notes from phone calls. Keep copies of any correspondence about the assessment, including the date and time of the assessment, the name and qualifications of the medical practitioner, and any instructions provided.
Second, if the insurer fails to act in good faith or does not respond to your concerns, you may lodge a formal complaint with SIRA. SIRA provides a dedicated process for handling complaints about insurer conduct. You can submit a complaint online via the SIRA website or by post. SIRA will assess the complaint and may mediate between you and the insurer, or refer the matter to a formal review if necessary.
Evidence That Matters in Disputes About Medical Assessments
When disputing an insurer’s handling of a medical assessment, the following evidence is typically relevant:
- A copy of the insurer’s written notice of the assessment, including the proposed date, time, and location.
- The medical practitioner’s qualifications and registration details.
- Records of your injury, including medical reports, treatment notes, and any prior assessments.
- Evidence of any delays, miscommunications, or inconsistencies in the insurer’s correspondence.
- A record of any requests you made to reschedule or clarify the assessment.
SIRA may also consider whether the insurer followed the Motor Accident Injuries (Medical Assessment) Regulation 2017, including whether the assessment was conducted in a timely manner and whether the claimant was given a reasonable opportunity to attend.
Time Limits and Procedural Requirements
There is no fixed time limit for lodging a complaint with SIRA about insurer conduct, including the preparation for medical assessments. However, it is important to act promptly. Delays may affect SIRA’s ability to investigate the matter, particularly if evidence is lost or witnesses are no longer available.
If you are seeking to challenge a decision made during or after a medical assessment, such as a denial of benefits or a determination of impairment, you must be aware of the time limits for appealing that decision. For example, a claimant must generally apply to SIRA for a review of a medical assessment decision within 12 months of receiving the assessment report.
When to Seek Independent Advice
Disputes about medical assessments can be complex, particularly when there are disagreements about the nature or severity of injuries. If you believe your insurer is not acting fairly or is not following the legal requirements, it may be appropriate to seek independent advice from a legal practitioner or a claims assessor who is experienced in CTP matters.
SIRA does not provide legal advice, and its role is to investigate conduct, not to determine entitlement to benefits. If you are considering a formal complaint, it is advisable to ensure your evidence is complete and your concerns are clearly documented.
A Practical Example
A claimant in the Hunter region was notified by their insurer of a medical assessment scheduled for two days’ notice, with no option to reschedule. The claimant had ongoing back pain and was required to travel 60 kilometres to attend. The insurer did not provide a copy of the medical practitioner’s qualifications or explain the purpose of the assessment. The claimant submitted a complaint to SIRA, including evidence of the short notice, travel burden, and lack of documentation. SIRA reviewed the complaint and found the insurer had not met procedural standards. The insurer was directed to reschedule the assessment with proper notice and to provide a qualified medical practitioner.
Next Steps
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