CTP Claim Denied, Reduced or Cut Off? Your Options in NSW

What 'denied' can actually mean

People say their claim was denied when the insurer has made one of several quite different decisions. The type of decision affects the review path and the time limits, so start by identifying which one you have:

• Liability declined: the insurer won't accept the claim at all, or says the injury wasn't caused by the accident.
• Fault: the insurer says you were wholly or mostly at fault, which generally limits benefits to 52 weeks and rules out damages (see at fault vs not at fault).
• Late claim: the insurer won't accept your explanation for claiming late, or won't back-pay weekly payments.
• Threshold injury: the insurer says your injury is a threshold injury, which limits benefits and rules out damages (see threshold injury disputes).
• Treatment refused: the insurer says a treatment is not reasonable and necessary, or not related to the accident.
• Weekly payments: the insurer has calculated them too low, reduced them, or stopped them because it says you can work.

Step 1: Get the decision in writing and read it closely

If you were told about a decision by phone, ask for it in writing. The written decision should explain what was decided, the reasons, the evidence relied on and how to seek a review. Ask for copies of any reports the insurer relied on, including independent medical examination reports.

Step 2: Internal review by the insurer

If you disagree with most insurer decisions, you can ask the insurer for an internal review, generally within 28 days of receiving the decision. The review is done by someone at the insurer who wasn't involved in the original decision.

The insurer usually has 14 days to decide (21 days for some medical and miscellaneous matters, and up to 28 days if it needs more information). Internal review is your chance to put forward new evidence and explain, in plain terms, why the decision is wrong.

Step 3: The Personal Injury Commission

If you are still unhappy after internal review, you can apply to the Personal Injury Commission, an independent tribunal that has decided CTP disputes since 1 March 2021. Depending on the dispute, it may be decided by a merit reviewer, a medical assessor or a member of the Commission. See the Personal Injury Commission.

Evidence that changes decisions

Reviews are decided on evidence, not frustration. The things that most often shift a decision are:

• A detailed report from a treating specialist that answers the specific question in dispute.
• Imaging or tests that weren't available when the decision was made.
• A formal psychological or psychiatric diagnosis where a psychological injury is involved.
• Complete earnings records, for weekly payment disputes.
• Witness statements, footage or police records, for fault disputes.
• A clear explanation, with supporting documents, for any delay in claiming.

Where the medical evidence comes from

Most of the evidence that changes a treatment, injury or capacity decision comes from your treating doctor and allied health providers, not from a lawyer. If you need a doctor experienced with CTP claims who can write a report that answers the insurer's reasons, or a Certificate of Fitness that reflects your restrictions, see doctors and allied health.

Mistakes to avoid

• Letting the 28-day internal review window pass while you wait for a call back.
• Arguing by phone instead of in writing.
• Missing insurer medical examinations or ignoring information requests.
• Stopping treatment because it wasn't approved, without keeping records of your symptoms.
• Posting about your claim or your insurer on social media.

Free help, and complaints

CTP Assist, run by SIRA, gives free information and support about CTP claims on 1300 656 919. SIRA also funds a free CTP Legal Advisory Service for statutory benefits questions, although it doesn't cover damages claims or matters already at internal review or the Personal Injury Commission.

If your complaint is about how the insurer has behaved, rather than a decision, the Independent Review Office (IRO) handles complaints about CTP insurers on 13 94 76.

When to talk to a lawyer

Disputes are where legal help most often matters, because they turn on procedure, time limits and the right evidence. See CTP dispute lawyer for how we can connect you with one. Talk to an independent CTP lawyer if:

• The decision is about fault, a threshold injury or whole person impairment, since those decide whether damages are possible.
• Your weekly payments have been stopped or cut.
• Internal review has confirmed the decision and you are considering the Personal Injury Commission.
• You are close to, or past, the review deadline.