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Step by step guide to checking and disputing insurers’ decisions.

Give yourself the best chance of success by following these tips.

This article will guide you through the process of checking your payments and disputing the insurers’ assessment if you believe it’s wrong. If you haven’t already done so, we recommend you start by reading What you need to know about checking and disputing insurer’s decisions – this will help you understand more about your payments, and the reasons why you might need to lodge a dispute.

Step 1:Checking your medical, treatment and care payments.

Here’s a quick summary of entitlements, to help you determine if you’re getting what you should be:

Injury/ months since accident	Medical, treatment and care expense entitlements
All injuries, first six months	You’re entitled to have your treatment and care expenses reimbursed. If your expenses are not being paid by the insurer, you should consider disputing the insurer’s decision.
Minor injuries, beyond six months	The insurer has the discretion to continue to pay for treatment and care. In most cases the scheme assumes that you’ll recover from minor injuries within six months.
Non-minor injuries, beyond six months	The insurer should continue to pay for your treatment and care expenses.
All injuries, beyond 24 months	You won’t receive any further payments, and you’ll need to apply for a lump sum benefit to cover any ongoing expenses.

Step 2:Checking your income support payments.

Similar rules apply to income support:

Injury/ time since accident	Income support payment entitlement
Weeks 1-13	You’re entitled to receive up to 95% of your pre-accident earnings.
Weeks 14-26 (i.e. up to six months)	You’re entitled to receive up to 80-85% of your pre-accident earnings.
Minor injuries, beyond six months	You won’t receive any further income support.
Non-minor injuries, beyond six months	The insurer should continue to pay your income support payments for a maximum of 24 months, or until your claim for lump sum benefits has been approved. The lump sum claim will take into account your injuries and your ability to earn an income in the future.
All injuries, beyond 24 months	You won’t receive any further payments and you’ll need to apply for a lump sum benefit to cover any ongoing lost income.

To assess your pre-accident income, the insurer will ask you for evidence of your earnings, like twelve months’ pay slips. Then the insurer will estimate your income by taking an average.

What you should realise is that there are a number of ways this could be unfair to you. Here are two examples:

If you took unpaid leave during the last year, your payslips wouldn’t show this and your income assessment based on a 12-month average would be too low.
If you changed jobs or received a recent promotion and your new job paid a much higher income than your old job, then your 12-month average would be lower than your actual pre-accident earnings, which would be unfair to you.

You can request information from the insurer about how they calculated your income. Once you get their reply, if you think they’ve got it wrong you can lodge a dispute to get it corrected.

This video explains how to check your payments in more detail.

Step 3:Lodging a dispute.

If you’ve checked your payments and you believe they’re wrong, or you’re being denied “reasonable and necessary treatment”, you should lodge a dispute with the insurer.

It’s at this point that you should engage a lawyer. For most disputes SIRA allows you to engage a lawyer at no cost to you. Please call 1800 888 529. to find out if this applies to your dispute.

The following table lists the steps you’ll need to go through in order to dispute your payments. Please note that if you’ve engaged a lawyer, they will handle the whole process on your behalf.

The first step in the dispute process is to request an “Insurer Internal Review”, or IIR. After the insurer has provided you with their IIR determination, if you’re unhappy with the outcome, you can escalate the dispute to SIRA’s Dispute Resolution Service (DRS).

Steps	Helpful information
Step 1 – Insurer Internal Review (IIR)	You must do this within 28 days of receiving the liability notice letter from the insurer. Requesting an IIR can be done over the phone with the insurer, or you can send them a letter requesting an IRR. Here’s a letter template you can use. If your dispute is about lost wages, you’ll need to provide the insurer with evidence that shows how they’ve miscalculated your weekly entitlements. You’ll also need to explain why you believe the insurer’s calculation is wrong. Here’s a link to a letter you can use as a template.
Step 2 – Dispute Resolution Service	You have a maximum of 28 days to lodge an application to DRS – click here to download the form you’ll need to complete. If your dispute is being handled by the DRS, and a specialist medical opinion is needed, that opinion must come from a SIRA approved doctor. You’ll be referred to an approved doctor.

Steps

Helpful information

Step 1 – Insurer Internal Review (IIR)

You must do this within 28 days of receiving the liability notice letter from the insurer.
Requesting an IIR can be done over the phone with the insurer, or you can send them a letter requesting an IRR. Here’s a letter template you can use.
If your dispute is about lost wages, you’ll need to provide the insurer with evidence that shows how they’ve miscalculated your weekly entitlements.
You’ll also need to explain why you believe the insurer’s calculation is wrong.
Here’s a link to a letter you can use as a template.

Step 2 – Dispute Resolution Service

You have a maximum of 28 days to lodge an application to DRS – click here to download the form you’ll need to complete.
If your dispute is being handled by the DRS, and a specialist medical opinion is needed, that opinion must come from a SIRA approved doctor.
You’ll be referred to an approved doctor.

Step 4:Getting help with lodging a dispute.

Strict time limits apply to IIR and DRS dispute applications. However, you’re entitled to get legal assistance to help you submit your dispute so it’s best to get legal advice as quickly as possible.

Remember, SIRA generally allows you to engage with a lawyer to represent you at DRS at no cost to you. Call 1800 888 529 and speak directly to a specialist CTP lawyer to understand the options available to you. It’s a free service.

What do I do next?

Make sure the insurer is paying for all the treatment and care expenses you’re entitled to.
Check your income support payments, to make sure you’re not being under-paid.
Call our advice line if you’re planning to lodge a dispute – it’s a free service.

“There are so many ways the insurer can get it wrong. If your income assessment is too low, and you don’t know how to argue your case, you won’t get your full compensation entitlements.

Liability limited by a scheme approved under Professional Standards Legislation. Legal Practitioners employed by Law Partners Compensation Lawyers Pty Ltd are members of the scheme.