Dispute a decision under the NSW CTP insurance scheme
The State Insurance Regulatory Authority (SIRA) set up the Dispute Resolution Service (DRS) to manage disputes that arise during the claims process. On 1 March 2021, functions of the DRS, the Motor Accidents Claims Assessment (CARS) and the Motor Accidents Medical Assessment Service (MAS) transferred to a new Personal Injury Commission (PIC).
The PIC now manages disputes with insurers about claims under the CTP (and workers compensation) schemes.
Types of dispute
Five types of dispute can arise in each stage of the process of making a CTP claim:
- Internal review
- Merit review
- Medical assessment
- Miscellaneous claims assessment
- Damages claims assessment.
The insurer handles the earliest kind of dispute in a CTP claim. This is an internal review, where the insurer revisits its original decision about the claim.
The PIC handles the next four types of dispute. It appoints a decision-maker to act as the disputing party’s contact person with the PIC.
An internal review must be undertaken before you can proceed to the next level of review, except for disputes about the degree of permanent impairment.
A request for any review or assessment does not stop the original decision and the insurer still acts on that decision until a new decision is made.
1. Internal review
What is it?: An insurer-appointed independent reviewer revisits the original insurer decision.
Time to apply: Within 28 days of the insurer’s original decision.
- Apply to the insurer online, using the insurer application form, by phone or in writing.
- The reviewer conducts a review of all evidence, which may be via teleconference, videoconference, or face to face meetings (the insurer must conduct the review in a way that is appropriate given the facts and circumstances of the claim).
- The reviewer must decide within 14 days of application.
- No legal costs are payable.
2. Merit review
What is it?: PIC review of insurer’s internal review decision to check for legal and factual correctness.
Time to apply: Within 28 days of internal review decision.
- Apply to the PIC by linking to the PIC online portal.
- A decision-maker will revisit the insurer’s internal review decision.
- You will receive a new decision within 28 days of your application.
- Legal costs may be payable.
- If you are not satisfied with the merit reviewer’s decision, you can apply within 21 days for merit review by a review panel.
3. Medical assessment
What is it?: Further assessment by one or more medical practitioners of your medical condition, eg, degree of permanent impairment, whether treatment and care is reasonable, what is threshold injury.
Time to apply: Within 28 days of insurer’s internal review decision.
- Apply to the PIC by linking to the PIC Portal.
- PIC-appointed medical assessor conducts the review and the insurer pays your costs to attend.
- Legal costs may be payable.
- If the medical assessor’s decision is unacceptable, you can apply within 28 days for medical assessment by a review panel.
4. Miscellaneous claims assessment
What is it?: PIC assesses claims that are neither administrative nor medical, eg, who was at fault, contributory negligence or whether the accident actually caused the injuries.
Time to apply: Within 28 days of the insurer’s internal review decision.
- Apply to the PIC by linking to the PIC Portal.
- The insurer must reply within 7-21 days of an application.
- The PIC may contact both parties to narrow or resolve issues.
- PIC decision-maker makes miscellaneous claims assessment then makes decisions with brief reasons.
- Both you and the insurer receive PIC decision and brief reasons within 7 days of assessment.
- Legal costs are payable.
- No panel review is available.
5. Damages claims assessment
What is it?: PIC makes an assessment when you and the insurer cannot agree on a proposed settlement. You must first use best endeavours to settle the claim before applying for damages claim assessment.
Time to apply: Apply at any time.
- Apply to the PIC by linking to the PIC Portal.
- The PIC claims assessor makes a decision within 21 days of assessment.
- Legal costs are payable.
- You can request another claims assessment only if significant new evidence is produced in court.
Damages settlement approval
If you are not legally represented, then the PIC must first approve any proposed settlement.
You and the insurer must seek PIC approval for the agreed damages settlement. The insurer will apply to the PIC within 7 days of agreeing on a proposed settlement with you and the PIC must respond within 7 days of application.
Note: Claims for damages are permitted to be settled within 2 years of the accident if the injured person suffers less than 10% whole person impairment.
Contact details for the Personal Injury Commission:
www.pi.nsw.gov.au
Online portal: https://pi.nsw.gov.au/lodge-a-dispute/applying-online
Phone: 1800 742 679
Email: help@pi.nsw.gov.au
| Dispute | What is it? | Deadline | Review or Assessment | Decision | Panel Review | Legal Costs |
| Internal Review | Insurer-appointed independent reviewer reviews original insurer decision | Within 28 days of insurer decision apply to insurer | Insurer conducts review | Within 14 days of application | NA | None |
| Merit Review | Review of insurer internal review for legal and factual correctness, eg, funeral expenses, weekly payments | Within 28 days of receiving internal review assessment apply to PIC | Within 7-14 days PIC conducts review | Within 28 days of application | Within 21 days of PIC decision | May be payable |
| Medical Assessment | Further assessment of claimant’s medical condition, eg, degree of impairment, type of threshold injury | Within 28 days of receiving internal review assessment apply to PIC | PIC medical assessor conducts | Within 14 days of assessment | Within 28 days of PIC decision | Payable |
| Miscellaneous Claims Assessment | Claims not medical or administrative, eg, who was at fault, contributory negligence | Within 28 days of receiving internal review assessment any party can apply to PIC | In 7-21 days insurer asks PIC for assessment | Within 7 days of assessment | NA | Payable |
| Damages Claims Assessment | Claimant and insurer cannot agree on damages claim and have tried to settle it | Within 3 years of accident one party applies to PIC, within 21 days other party responds | PIC conducts assessment | Within 21 days of assessment | NA | Payable |
| Damages Settlement Approval | If self-represented, claimant and insurer must seek PIC approval for agreed damages settlement. Can be within 2 years for less than 10% WPI. | Within 7 days of agreement, insurer applies to PIC for approval | PIC assesses agreement | Within 7 days of assessment | NA | Payable |
Information in these tables is intended as a guide and for general information purposes only. It does not take into account your specific needs, objectives or circumstances, and is not advice. When making decisions about claiming, your insurance or any other matters, you must seek legal advice specific to your situation and you should not rely on these tables. While we use reasonable attempts to ensure the accuracy and completeness of the tables, we make no representation or warranting regarding the tables, to the extent permitted by law.