A letter refusing your CTP claim can feel final. It usually isn't. Most insurer decisions can be challenged, first by internal review and then at the Personal Injury Commission. If you live in The Entrance and the insurer has said no, our free claim check looks at the decision and its deadlines, and connects you with an independent CTP lawyer if a dispute is worth pursuing. Some aren't, and we'll tell you.
Central Coast · CTP claim denied
The Entrance: next steps for a refused CTP claim
The insurer's decision is rarely the last word. The first deadline is generally 28 days, so start now.
Postcode: 2261
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How to challenge a CTP decision, step by step
Insurers make decisions under the scheme rules, and the scheme also sets out how to challenge them. These are the main steps and the timeframes that generally apply.
Step 1
Read the decision letter
Read the letter twice: once for what was decided, once for why. Write down the date you received it. If the reasons aren't clear, ask the insurer to explain them in writing.
Within 28 days
Ask for an internal review
For most decisions, you can ask the insurer for an internal review, generally within 28 days of receiving the decision. Say what you disagree with and include any new evidence.
14 to 28 days
The insurer decides
The insurer usually has 14 days to decide the review. For some medical and miscellaneous matters it's 21 days, and up to 28 days if it needs more information from you.
If you still disagree
Apply to the Personal Injury Commission
If the internal review doesn't resolve things, you can generally apply to the Personal Injury Commission. It's independent of the insurer and decides disputes under the scheme rules.
28 days from a certificate
Medical assessment review
If your dispute goes to medical assessment and you think the certificate is wrong, a review must generally be sought within 28 days of the certificate being issued.
Any time
Conduct complaints go to the IRO
If your concern is how the insurer has treated you, such as delays or poor communication, that's a complaint, not a dispute. The Independent Review Office handles those complaints on 13 94 76.
General information, not legal advice. Timeframes are general, and some decisions follow different rules. Check your decision letter and get advice quickly.
Disputing a claim while living in The Entrance
If Gosford Hospital or Wyong Hospital treated you and the insurer has classified the injury as threshold, those records may help challenge it. A medical assessment certificate review, if it comes to that, has its own 28-day window. At around 65 km from the Sydney CBD, living in The Entrance is no disadvantage in a dispute. Review requests generally go in writing, many Personal Injury Commission steps can happen by phone or online, and our claim check works the same way. Your review rights don't depend on your council, whether that's Central Coast Council or any other. Internal reviews and the Personal Injury Commission work the same way across NSW.
- Region
- Central Coast
- Postcode
- 2261
- From the Sydney CBD
- ~65 km
- Local government area
- Central Coast Council
A refusal isn't the end of the road
Before deciding what to do, pin down three things: exactly what was decided, the reasons given, and the date you received the letter. The first two tell you what evidence might change the outcome. The third starts the clock, because an internal review is generally requested within 28 days. With those in hand, choosing between a review on your own and getting advice becomes much clearer.
Read next:CTP claim denied?
The decisions behind many disputes
Not every decision is a flat refusal. Sometimes the claim is accepted but limited: benefits capped at 52 weeks, weekly payments set lower than you expected, or a particular treatment declined. These partial decisions can matter as much as a refusal over time, and most can be reviewed in the same way.
- The injury was classed as a threshold injury
- You were found wholly or mostly at fault
- The crash is being treated as a work injury
- A treatment request was declined
Read next:Claim denied? Quick check
Medical and threshold disputes
A threshold decision about a psychological injury can be disputed like any other. If the insurer has classified yours as threshold and your treating practitioner disagrees, their written opinion is the starting point for an internal review. If the review doesn't resolve it, the dispute can go on to medical assessment at the Personal Injury Commission, where the 28-day window for a certificate review applies.
Read next:Threshold injury disputesWhen the insurer says “threshold injury”
Free claim check
Disagree with a decision? Start here
The claim check is free and carries no obligation. Tell us what the insurer decided, and we'll point you to the right help.
When a dispute calls for legal help
Whether you need a lawyer depends on what was decided and what's at stake. Use these lists to get a sense of it, then get a free claim check for your own situation.
Often worth talking to a lawyer
- The dispute is heading to the Personal Injury Commission
- You were driving for work and the insurer has refused on that basis
- You've missed the review deadline
- Weekly payments were stopped and you can't work
You may not need one
- Your doctor can clearly answer the insurer's question in a report
- The decision was about a small, one-off expense
- A treatment request was declined for lack of information you can supply
If your threshold dispute depends on whether there's nerve damage or a tear, the right assessment matters. Ask us about doctors and allied health experienced with CTP claims, from diagnosis to the Certificate of Fitness.
Not quite your situation?
- If you're not sure a dispute is worth taking on with legal help, the CTP lawyer page explains when a lawyer tends to be worth it. CTP lawyer in The Entrance
- When the real argument is how serious your injury is, the injury compensation page for The Entrance covers impairment and the threshold line. Injury compensation lawyer in The Entrance
- If you haven't had a decision yet and are still getting the claim in, start with the CTP claims page for The Entrance. CTP claims in The Entrance
Making your internal review count
An internal review is a fresh look at the decision by the insurer. Ask in writing, generally within 28 days of receiving the decision. Say which decision you disagree with, why you think it's wrong and what outcome you want. Attach anything new: a report from your doctor, hospital records, payslips or witness details.
After you ask, the insurer usually has 14 days to decide. Some medical and miscellaneous matters allow 21 days, and up to 28 days if the insurer needs more information. While you wait, keep sending updated Certificates of Fitness if you're off work, and keep a record of every contact about the review.
The 28-day window
The clock generally runs for 28 days from the day the decision reached you. Note the date the letter arrived, not just the date printed on it.
Read next:Insurer stopped my weekly payments
Complaints versus disputes
A dispute is about a decision, such as whether your claim is accepted. A complaint is about conduct, such as delays, unanswered calls or unclear letters. Complaints about the conduct of CTP insurers go to the Independent Review Office (IRO) on 13 94 76, 8:30am to 5:30pm weekdays, or online at iro.nsw.gov.au. The IRO doesn't fund lawyers for CTP claims.
Taking a dispute further
If an internal review doesn't resolve your dispute, the Personal Injury Commission is generally the next step. It's independent of the insurer. Depending on the dispute, a member may review the decision on its merits, a medical assessor may assess your injury, or the Commission may assess a damages claim. The type of dispute decides which path applies.
Read next:The Personal Injury CommissionPIC disputes explained
What a dispute might cost
Free help is limited once a dispute is under way. The CTP Legal Advisory Service that SIRA funds stops short of matters already at internal review or before the Personal Injury Commission. CTP Assist can still give general information. For advice on the dispute itself, you'll generally need an independent lawyer.
Read next:What does a CTP lawyer cost?
Frequently asked questions
First, check the letter for the reason. Payments may stop because the insurer says you can work, because your benefit period has ended, or for another reason under the scheme rules. If you disagree, ask for an internal review, generally within 28 days. Keep your Certificates of Fitness up to date in the meantime, and get advice if you can't work.
Usually 14 days from your request. Some medical and miscellaneous matters give the insurer 21 days, and it can take up to 28 days where it needs more information from you. If you haven't heard within those times, follow up in writing. If the delay itself is the problem, you can also complain to the Independent Review Office.
Insurers make decisions under the scheme rules, and a refusal usually points to one of them. Common grounds include a claim lodged late, an injury classed as threshold, a finding that you were mostly at fault, or a view that the crash falls under a different scheme. The decision letter should give reasons, and those reasons tell you what evidence might change the outcome.
Only in part. SIRA's CTP Legal Advisory Service gives free advice on statutory benefits for accidents from 1 December 2017, but it doesn't cover matters already at internal review or the Personal Injury Commission, damages claims or older-scheme claims. It may help before you request a review. Once a dispute is under way, you'd generally need an independent lawyer.
Generally 28 days from receiving the decision. Ask in writing, say which decision you disagree with and why, and include any new evidence. Because the window is short, don't wait for every document before you lodge the request. If you're close to the deadline or past it, get advice quickly.
Not in the usual sense. If you were driving for work, or the crash otherwise happened in the course of your work, workers compensation through your employer's insurer is generally the claim to make first, and CTP statutory benefits are generally not payable where workers compensation is available. That's a question of which scheme applies, not a finding about your injury. A CTP damages claim against the at-fault driver's insurer may still be possible, so get advice. The work quick check is a sensible first step.
CTP claim denied: suburbs near The Entrance
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CTP Lawyer is not a law firm. This page is general information, not legal advice; the independent lawyer you speak with can advise on your own situation.