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Step by step guide to checking and disputing insurer’s 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 insurer’s assessment if you believe it’s wrong. If you haven’t already done so, we recommend you start by reading our article on 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.

If your injuries are assessed as being minor, you’re entitled to have your treatment and care expenses reimbursed for up to six months. If your expenses are not being paid by the insurer, you should consider disputing the insurer’s decision. Beyond six months the insurer has the discretion to continue to pay for treatment and care, but in most cases the scheme assumes that you’ll recover from minor injuries within six months.

If your injuries are assessed as being non-minor, then the insurer will continue to pay for your treatment and care expenses beyond six months. 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: Check your lost wages.

The same applies to your lost wages.  If your injuries are assessed as minor, then you’ll only be reimbursed for your lost wages for a maximum of six months.  If your injuries are assessed as non-minor then you’ll be able to receive these benefits 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.

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 make an estimate of your income by taking an average.

What you should realise is that there are a number of ways this could be unfair to you. For example, 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.

Another example could be 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.

If the insurer’s assessment of your income is too low, it will immediately reduce your weekly payments while you’re off work, and it could also reduce any future lump sum claim you can make for past economic loss. So making sure your income is estimated correctly is very important.

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.

The video below 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 is at this point that you should engage with a lawyer. For most disputes SIRA allows you to engage with a lawyer at no cost to you.  Please call our free advice line to understand whether this applies to your dispute and find out where you stand.

The first step in the dispute process is to request an “Insurer Internal Review”, or 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. This evidence may include:

You’ll also need to provide a letter that explains why you believe the insurer’s calculation is wrong. Here’s a link to a letter you can use as a template.

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). 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.

If you wish to progress and have your dispute heard by DRS, then strict time limits apply between lodging an internal review and escalating to the DRS, so it’s important that you seek legal assistance straight away.  If you miss the cut-off date, you’ll have no further options open to you to claim statutory benefits.

You’re entitled to get legal assistance to help you submit your dispute. A personal injury lawyer who’s experienced in successfully disputing insurers’ decisions can review your dispute and the evidence you’re planning to submit, and advise you on how to give yourself the best possible chance of success.

Generally, SIRA allows you to engage with a lawyer to represent you at DRS at no cost to you. There are some “unpaid” disputes where a lawyer’s not allowed to charge for their time, however, to give yourself the best possible chance of success, please call our free advice line and speak directly to a CTP personal injury specialist to understand the options available to you.

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.

– Adrian Pin, Managing Director of Australia’s largest specialist personal injury law firm.

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.

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