How To Review Decisions Made by the Insurer

How To Review Decisions Made By The CTP Insurer

There could be various reasons behind the decision of the CTP insurer such as the belief that you can return to work, your injuries have resolved, the medical treatment is not necessary for your recovery, or you have reached the maximum period of time you are entitled to receive benefits based on the assessment of your injuries. 


It is crucial to remember that you have the right to challenge any decision made by the CTP insurer if you believe the decision is incorrect.

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HAS THE CTP INSURER DECIDED YOU ARE AT FAULT?

In order to cease statutory benefits, the insurer must make a decision based on one of the following grounds:


  1. The motor accident was primarily or mostly caused by the fault of the person claiming statutory benefits.
  2. The person claiming statutory benefits suffered only minor injuries as a result of the motor vehicle accident.


If the insurer can establish that one of these circumstances applies, statutory benefits will cease after 52 weeks.

WHAT IS CONTRIBUTORY NEGLIGENCE?

Contributory negligence is a concept used to measure the relative culpability of each party involved, such as drivers, passengers, pedestrians, or cyclists.


Insurers must include in any letter denying liability for your claim ‘in whole or in part’ provide you with the following:


  1. An explanation of why a decision must be made.
  2. An explanation of the consequences of the decision.
  3. The reason why the insurer has made the decision ‘with reference to the information relied upon in making the decision’.
  4. A list of all information relevant to the decision, regardless of whether the information supports the decision. The insurer must provide copies of all listed information to the claimant.

HAS THE CTP INSURER DENIED ACCESS TO MEDICAL TREATMENT?

Prompt access to necessary treatment plays a crucial role in an injured person's recovery from motor accident injuries and their ability to return to work efficiently. The complexity of the legislation often leads to treatment denials, forcing injured individuals to navigate a lengthy process of gathering evidence to justify their treatment needs. As a result, significant delays occur, hindering optimal recovery and return to work outcomes. 


Common reasons for the denial of treatment are as follows:

Inability to Contact the Treatment Provider

The CTP insurer may deny treatment if they are unable to reach the treatment provider for verification or further clarification about the request for treatment.

Insufficient Information

If the injured accident victim or their treatment provider fails to provide enough information to justify the need for the treatment the CTP insurer may decline to approve the treatment.

Unrelated Treatment

The CTP insurer may make a decision to decline to approve treatment if it is believed that the requested treatment is not directly related to the motor accident because of pre-accident health issues or an overlap in injuries suffered by the injured accident victim.

Lack of Reasonableness and Necessity

The CTP insurer may deny treatment if they believe it does not meet the criteria of being reasonable and necessary for the injured person's recovery.

Non-Approved or Excessive Cost

The CTP insurer may deny treatment if the cost of the treatment exceeds the approved limits or exceeds the AMA rates.

Unlikely Improvement

The CTP insurer may deny treatment if it is determined that the proposed treatment is unlikely to lead to functional improvement or an increase in the injured person's capacity to return to work.

Facing a denial of treatment from the CTP insurer can be an overwhelming and distressing experience. For help on what to do next, speak to CTP Claim Guide, we are here to help.

WHAT DO I DO NEXT?

As a claimant, you have the right to request and review the information gathered by the insurer to ensure transparency and fairness in the process. The two main steps you can take to challenge a decision made by the CTP insurer:

STEP ONE

Request An Internal Review of the Decision Made by the CTP Insurer

If you disagree with the CTP insurer's decision on the question of fault, decline your access to medical treatment or rehabilitative treatment or to reduce or terminate your income support benefits, you can request an internal review be undertaken. This means you are asking the CTP insurer to escalate the decision to the internal review team who will review your case file again and reconsider the decision. 


You can provide further evidence to the CTP insurer at the time you request the review – perhaps a document that was not available at the time the decision was made or something which you feel the CTP insurer has overlooked.


The CTP insurer will provide you with a letter outlining the reasons for its decision made on review.

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STEP TWO

Escalate the Dispute to the Personal Injury Commission

The Personal Injury Commission is a government body responsible for resolving disputes related to personal injury claims in New South Wales. The aim of the Personal Injury Commission is to provide a fair, timely, and cost-effective dispute resolution process for all parties. It also aims to promote the early resolution of disputes between injured claimants and CTP insurer.


In most cases, it is necessary to request an internal review by the CTP insurer before lodging the dispute with the Personal Injury Commission.

Seeking legal assistance in these matters does not come with any financial burden on your part. If you choose to engage a lawyer for a dispute, their fees will be covered by the CTP insurer. At CTP Claim Guide, we can help you with this dispute.

ASKING A CTP INSURER FOR CLARIFICATION

It is important to note that these are common reasons for treatment denials, but each case is unique, and specific circumstances may impact the decision. 


Seeking clarification from the CTP insurer and, if necessary, consulting with a legal professional experienced in CTP claims can help address the denial and advocate for treatment necessary for your recovery.


You should talk to your doctors and other health care providers (physiotherapists, counsellors) about what treatment you need and if your treatment is denied provide a copy of the decision to your doctor and ask that they provide a letter in response setting out why the treatment is necessary.


Do not be shy about asking the Insurer for treatment or care or travelling expenses. They will often not volunteer it.

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Car with a Destroyed Frontend after an accident

FREQUENTLY ASKED QUESTIONS

  • Can I challenge a decision made by the CTP insurer that I don’t agree with?

    The majority of decisions made by a CTP insurer can be reviewed by the Personal Injury Commission. 


    Once the CTP insurer communicates their decision to you in writing, you have the right to request an internal review within 28 days. 


    If the internal review does not result in a satisfactory outcome, you then have the option to lodge a dispute with the Personal Injury Commission.


    It's essential to be aware that the internal review process and proceedings within the Personal Injury Commission or Court can be lengthy, intricate, and emotionally taxing, especially for an injured accident victim who is unfamiliar with the procedures, rules, and regulations involved.

  • Is there a time limit for challenging a CTP insurer’s decision?

    Yes, any request for an internal review should be submitted to the CTP insurer within 28 days the decision being received.

  • Are there costs involved in challenging the decision of a CTP insurer?

    There are no costs payable by an injured claimant for challenging the decision of the CTP insurer on an internal review.

  • Do I need a CTP lawyer?

    Insurance companies have specialised teams that handle contact with injured accident victims. These teams are established because insurance companies understand that without legal representation, individuals may struggle to accurately assess their entitlements to compensation.


    While a CTP insurer might display occasional kindness during your claim, it's important to understand that they will never willingly offer you the maximum sum of compensation you are entitled to receive.


    We recommend that you engage an expert CTP lawyer to assist with every aspect of your claim.

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Submit the form below and we will have one of our expert CTP lawyers reach out to learn more about you and your circumstances and see if you are eligible. Start the CTP claim process now to get the compensation you deserve.

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