Claims – Disputing a Decision

Disputing 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) scheme.

Types of dispute

Five types of dispute can arise in each stage of the process of making a CTP claim:

  1. Internal review
  2. Merit review
  3. Medical assessment
  4. Miscellaneous claims assessment
  5. 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 DRS handles the next four types of dispute. It appoints a Dispute Resolution Officer (DRO) to act as the disputing party’s contact person with the DRS.

An internal review must be undertaken before you can proceed to the next level of review.

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.

  1. Apply to the insurer online, using the insurer application form, by phone or in writing
  2. 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)
  3. The reviewer must decide within 14 days of application
  4. No legal costs are payable.

2. Merit review

What is it?: DRS review of insurer’s internal review decision to check for legal and factual correctness
Time to apply: Within 28 days of internal review decision.

  1. Apply to the DRS by logging into Service NSW and linking to SIRA Portal
  2. A DRS merit reviewer will revisit the insurer’s internal review decision
  3. You will receive a new decision within 28 days of your application
  4. Legal costs may be payable
  5. 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 minor injury.
Time to apply: Within 28 days of insurer’s internal review decision.

  1. Apply to the DRS by logging into Service NSW and linking to SIRA Portal
  2. SIRA-appointed medical assessor conducts the review and the insurer pays your costs to attend
  3. Legal costs may be payable
  4. 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?: DRS 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.

  1. Apply to the DRS by logging into Service NSW and linking to SIRA Portal
  2. The insurer must reply within 7-21 days of an application
  3. The DRS may contact both parties to narrow or resolve issues
  4. DRS assessor makes miscellaneous claims assessment then makes decisions with brief reasons
  5. Both you and the insurer receive DRS decision and brief reasons within 7 days of assessment
  6. Legal costs are payable
  7. No panel review is available.

5. Damages claims assessment

What is it?: DRS 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 within 3 years of the date of the accident.

  1. Apply to the DRS by logging into Service NSW and linking to SIRA Portal
  2. The DRS claims assessor makes a decision within 21 days of assessment
  3. Legal costs are payable
  4. 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 DRS must first approve any proposed settlement.

You and the insurer must seek DRS approval for the agreed damages settlement. The insurer will apply to the DRS within 7 days of agreeing on a proposed settlement with you and the DRS must respond within 7 days of application.

Note: claims for damages cannot be settled within 2 years of the accident, unless the injured person suffers more than 10% whole person impairment.

Contact DRS:

Phone: 1800 DISPUTE or 1800 34 77 88
Visit: Level 6, McKell Building, 2-24 Rawson Place, Sydney from 8.30 to 5pm on weekdays.

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 DRS Within 7-14 days DRS conducts review Within 28 days of application Within 21 days of DRS decision   May be payable
Medical Assessment Further assessment of claimant’s medical condition, eg, degree of impairment, type of minor injury Within 28 days of receiving internal review assessment apply to DRS DRS medical assessor conducts Within 14 days of assessment  Within 28 days of DRS 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 DRS In 7-21 days insurer asks DRS 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 DRS, within 21 days other party responds DRS conducts assessment Within 21 days of assessment  NA Payable
Damages Settlement Approval If self-represented, claimant and insurer must seek DRS approval for agreed damages settlement. (Not within 2 years unless 10% WPI.) Within 7 days of agreement, insurer applies to DRS for approval  DS 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.

Claims Guide - more info

Overview >

Learn about entitlements, making a claim, getting advice and disputing a decision. read more

Entitlements >

Your entitlement to benefits and damages under the NSW CTP green slip scheme. read more

Making a claim >

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Getting advice >

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