Disputing an Insurer's Decision: A Guide to the NSW CTP Internal Review Process

Navigating a Compulsory Third Party (CTP) claim in New South Wales can be a complex procedure, particularly when a dispute arises. When an insurer makes a decision regarding your claim that you disagree with—such as declining liability, refusing a treatment request, or ceasing statutory benefits—you have the right to challenge it. The first formal step in disputing most insurer decisions is requesting an Internal Review.

This comprehensive guide outlines the Internal Review process within the NSW CTP scheme, explaining your rights, the required timeframes, and how to effectively present your case. Understanding this process is critical to ensuring your entitlements are properly assessed in accordance with the Motor Accident Injuries Act 2017 (NSW) and the relevant State Insurance Regulatory Authority (SIRA) Motor Accident Guidelines.

An Internal Review is a formal process where the CTP insurer is required to reconsider a decision they have made regarding your claim. Importantly, this review is not conducted by the same claims officer who made the original decision. Instead, it must be assigned to an independent internal reviewer—usually a senior staff member within the insurer’s organization who had no prior involvement in the handling of your specific claim or the decision in question.

The purpose of the Internal Review is to provide a fair, objective, and timely secondary assessment of the evidence. It allows the insurer to correct potential errors, consider new medical or factual evidence that may not have been available initially, and ensure their decision complies strictly with the legislation and SIRA Guidelines.

Not all decisions made by an insurer are subject to an Internal Review, but many critical determinations are. The most common decisions that claimants dispute through this process include:

• Liability for Statutory Benefits: The insurer determining that you are wholly or mostly at fault for the accident, which may impact your entitlements after the initial period.
• Treatment and Care: The insurer refusing to fund a specific medical treatment, surgery, or rehabilitation service on the basis that it is not considered "reasonable and necessary."
• Weekly Income Support Payments: Disagreements regarding the calculation of your pre-accident weekly earnings (PAWE) or the cessation of your weekly payments.
• Threshold Injury Determinations: The insurer classifying your physical or psychological injuries as "threshold injuries" (formerly known as minor injuries). It is critical to note that a threshold injury determination is entirely separate from a Whole Person Impairment (WPI) assessment, which is a different clinical evaluation used primarily for assessing common law damages and ongoing statutory benefit eligibility.

The framework for resolving disputes in the NSW CTP scheme is heavily regulated. The SIRA Motor Accident Guidelines, particularly Part 7, establish the strict protocols insurers must follow when conducting Internal Reviews. Part 7 mandates that insurers must act transparently, communicate clearly with the claimant, and adhere to statutory timeframes.

The guidelines require the insurer to provide written notice of their original decision, detailing the reasons for the decision and providing the specific evidence relied upon. They must also explicitly inform you of your right to request an Internal Review and the timeframe within which you must do so.

Strict adherence to timeframes is crucial in the NSW CTP scheme. Failing to meet deadlines can result in the loss of your right to dispute a decision.

• Requesting the Review: Generally, you have 28 days from the date you receive the insurer's original decision to lodge a request for an Internal Review.
• The Insurer's Response: Once you submit a valid request, the insurer typically has 14 days to conduct the review and issue a new decision.
• Extensions: In some specific circumstances, or if additional medical information is required and agreed upon, these timeframes can be extended, but this should be formally documented.

To request an Internal Review, you must complete the specific Internal Review application form provided by the insurer or SIRA. A successful application relies heavily on how well it is prepared. You should:

1. Identify the Decision: Clearly state which decision you are disputing (e.g., the letter dated [Date] declining physical therapy).
2. State Your Reasons: Explain exactly why you believe the original decision is incorrect. Reference specific facts of your case.
3. Provide Supporting Evidence: This is the most critical step. If treatment was denied, include a detailed report from your treating doctor explaining why the treatment is reasonable and necessary. If income is disputed, provide payslips or tax returns.
4. Submit Promptly: Ensure the application is submitted within the 28-day window. Keep a record of your submission.

The internal reviewer’s mandate is to look at the disputed decision with fresh eyes. They must review all the information available at the time of the original decision, plus any new information you have provided in your application. They are bound by the SIRA Guidelines to make an independent determination based solely on the merits of the evidence and the application of the relevant CTP legislation.

Once the Internal Review is complete, the reviewer will issue a Certificate of Determination or a written notice outlining the outcome. The possible outcomes are:

• Affirm the Decision: The original decision is upheld.
• Vary the Decision: The original decision is changed in some part (e.g., approving 5 physiotherapy sessions instead of the requested 10).
• Overturn the Decision: The original decision is completely reversed in your favor.

The notice must include detailed reasons for the review decision, the evidence considered, and information on what you can do if you remain dissatisfied with the outcome.

If the insurer affirms or varies the decision in a way that you still disagree with, or if they fail to provide a decision within the required timeframe, the internal review process is considered exhausted. You then have the right to escalate the dispute to the Personal Injury Commission (PIC).

Depending on the nature of the dispute, it will be directed either to a Merit Review (for administrative and procedural disputes, like pre-injury earnings) or a Medical Assessment (for medical disputes, like treatment necessity or threshold injury classification). Escalating to the PIC involves a more formal, independent arbitration process.