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Fill out the form below to request a free claim check, and find out if you're entitled to additional benefits or a lump sum. Fill out the form below to request a free claim check, and find out if you're entitled to additional benefits or a lump sum. Call 1800 888 529.

What you need to know about checking and disputing insurer’s decisions.

If you don’t agree with the insurer’s decision, challenge it!

After you’ve lodged your statutory benefits claim, the insurer will send you a liability statement within 28 days. This letter will state the insurer’s decision on whether your injuries are minor, who was at fault in the accident and what payments you’ll be entitled to. But their decisions can be challenged, so it’s important that you check your payments and dispute them if you believe they’re wrong.

What happened to compensation?

Under the new CTP scheme, anyone who’s classified as having minor injuries will only be entitled to receive benefits for up to six months. Part of these benefits are referred to as “income support payments” – which sounds remarkably similar to terms like “child support payments”, which are government benefits. But the truth is, if you’ve been injured and need time off work, the payments you’re entitled to are not government benefits at all – they’re compensation payments made to you by the insurer, to cover your losses. So the payments should be based on your personal situation and the expenses or losses you’ve incurred. Even if you’ve been assessed as having a minor injury, the fact is that some injuries can continue to worsen beyond the initial six months, and you might still need compensation to help you financially while you recover.

Understanding your payments.

Here’s an explanation of how your statutory benefits, or weekly payments, are calculated by the insurer for the first six months after your accident. Statutory benefits are weekly payments from the insurer which cover three benefits:

  1. Medical and treatment expenses
  2. Care expenses
  3. Lost wages

Medical and treatment expenses will be reimbursed to you once you submit receipts to the insurer. After you lodge your application for personal injury benefits and the insurer assesses your injuries, they will generally approve a number of sessions with your GP and other treatment providers. Once you have this approval. the insurer will generally write directly to your provider and notify them.  Then the insurer will pay the GP or treatment provider directly, and these expenses won’t form part of your weekly statutory payments.

There’s no cap on the value of medical or treatment expenses reimbursed or pre-approved. Generally, you should receive whatever treatment is necessary to make sure you recover from your injuries.

Expenses for care you need are generally treated in the same way, but there’s a cap on the amount of care available depending on the severity of your injuries.

Then there’s income support – the weekly payments that cover your lost wages if you need time off work. For the first 13 weeks you’ll receive a maximum is 95 percent of your pre-accident earnings, then after 14 weeks the maximum is 85 percent.

If the insurer does cut off your benefits, they’ll need to give you four-weeks’ notice in writing of their decision.

The six-month threshold.

If you’ve been receiving benefits for injuries or time off work, and your benefits are being cut off, you’re not alone. In fact, the CTP scheme is designed so that most people won’t receive any benefits beyond six months, on the assumption they should be returning to work and their treatment should be complete.

But what if you still can’t work full time, or even work at all? And what if you need ongoing treatment?

Understanding the dispute process.

There are two steps you can take to dispute an insurer’s decision.

The first step in the dispute process is to request an “Insurer Internal Review, or IIR.

If you request an IIR, it means you disagree with the insurers decision to reduce or cut off all your benefits and you’re asking them to review your case file again.

For more information on this, please see our article on The most common disputes, and how to deal with them.

The letter you receive from the insurer four weeks before cutting off your benefits will outline their reasons for cutting you off.  You need to address each one of these reasons in your request for an IIR.

The second step, if you’re unhappy with the outcome of the insurer’s internal review, is to escalate the dispute to SIRA’s Dispute Resolution Service (DRS). You must request an IRR before you can take your matter into DRS.

The DRS will assist in one of two ways:

  1. Facilitate the understanding of issues in a dispute between insurer and injured persons to mutually resolve these disputes.
  2. Arrange an independent and binding decision by an expert assessor.

Now that you have more understanding of the process, you might like to proceed to our Step by step guide to checking and disputing your payments.

The biggest mistake you can make is simply accepting the insurer’s decision to cut off your benefits – the truth is, you may well be entitled to compensation you’re not being told about.

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

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