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CTP insurer claims experience and customer feedback comparison – Sept 2020

PDF version of this report is available.

Why does SIRA publish insurer data?

As part of its regulatory oversight, SIRA monitors insurers’ performance through data-gathering and analysis. SIRA helps to hold insurers accountable by being transparent with this data, enabling scheme stakeholders and the wider public to have informed discussions about the performance of the industry.

Additionally, access to insurers’ data will help customers make meaningful comparisons between insurers when purchasing CTP insurance. People injured in motor accidents may also benefit from knowing what to expect from the insurer managing their claim.

In this report, SIRA compares six key indicators of customer experience across the five CTP insurers in NSW: AAMI, Allianz, GIO, NRMA and QBE.

The following evidence-based indicators measure insurer performance over the course of a claim journey:

  • the number of statutory benefits claims accepted by insurers
  • how quickly insurers pay statutory benefits
  • the outcome and time taken to review claim decisions by insurers through the insurers internal review unit
  • the number and outcome of claims referred to the Dispute Resolution Service
  • the number and type of compliments and complaints received by SIRA about insurers
  • the number and type of issues escalated to SIRA’s Enforcement and Prosecutions team.

This issue of the report presents data for the first 3 measures above, over two time periods: 1 October 2018 to 30 September 2019 and 1 October 2019 to 30 September 2020. The report refers to these periods as years 2019 and 2020.  The other measures are presented as per the periods described in the respective sections of the report.

The CTP Insurer Claims Experience and Customer Feedback Comparison results are published each quarter. Future publications will benefit as SIRA continues to improve and expand its data collection and reporting capability.

How many claims did insurers accept?

Insurers accepted most claims from injured people and their families. Over 98% of claims were accepted in both 2019 and 2020. More detail on the rejected claims is provided on the following table.

Table – CHART 1: Claims Acceptance Rates by Insurer, comparing 2019 and 2018 years

Insurer

Year

Percentage of claims accepted

Percentage of claims rejected

Number of claims accepted

AAMI

2020

98.0%

2.0%

832

AAMI

2019

99.4%

0.6%

955

ALLIANZ

2020

97.5%

2.5%

1,924

ALLIANZ

2019

98.2%

1.8%

2,050

GIO

2020

97.7%

2.3%

1,682

GIO

2019

99.4%

0.6%

2,018

NRMA

2020

98.0%

2.0%

3,079

NRMA

2019

97.4%

2.6%

3,557

QBE

2020

99.7%

0.3%

2,418

QBE

2019

99.8%

0.2%

2,582

Total

2020

98.3%

1.7%

9,935

Total

2019

98.6%

1.4%

11,162

Why were claims declined?

Insurers decline claims in certain circumstances under NSW legislation.

The most common reasons for claim denial included:

  • late claim lodgement (more than 90 days after their accident),
  • insufficient information provided to the insurer,
  • the claim did not involve a motor vehicle accident.

1.7% of claims were declined by insurers in 2020, compared with 1.4% in the 2019 year. There were 9,935 total claims accepted in 2020, down from 11,162 in 2019.

  • Figures exclude claims which were declined because customers were covered by another scheme/insurer.

Table: Total Claims rejected in 2020 and 2019

Insurer

2020 Number of claims rejected

2019 Number of claims rejected

AAMI

17

6

ALLIANZ

49

37

GIO

39

13

NRMA

62

95

QBE

7

6

Total

174

157

Table: Claims rejected due to late lodgement for 2020 versus 2019

Insurer

2020 Number of claims rejected due to late lodgement (more than 90 days after accident)

2019 Number of claims rejected due to late lodgement (more than 90 days after accident)

AAMI

6

5

ALLIANZ

22

11

GIO

21

7

NRMA

36

46

QBE

5

2

Total

90

71

Table: Claims declined because insufficient information was provided to the insurer 2020 versus 2019

Insurer

2020 Number of claims declined because insufficient information was provided to the insurer

2019 Number of claims declined because insufficient information was provided to the insurer

AAMI

3

1

ALLIANZ

0

0

GIO

7

5

NRMA

0

16

QBE

0

0

Total

10

22

Table: Claims declined because the claim did not involve a motor vehicle accident

Insurer

2020 Number of claims declined because the claim did not involve a motor vehicle accident

2019 Number of claims declined because the claim did not involve a motor vehicle accident

AAMI

4

0

ALLIANZ

13

20

GIO

4

1

NRMA

5

4

QBE

0

1

Total

26

26

Table: Claims declined because the claim involved an uninsured, unregistered or unidentified vehicle

Insurer

2020 Number of claims declined because the claim involved an uninsured, unregistered or unidentified vehicle

2019 Number of claims declined because the claim involved an uninsured, unregistered or unidentified vehicle

AAMI

1

0

ALLIANZ

9

5

GIO

2

0

NRMA

5

6

QBE

0

1

Total

17

12

Table: Number of claims declined because the claim related to a serious driving offence

Insurer

2020 Number of claims declined because the claim related to a serious driving offence

2019 Number of claims declined because the claim related to a serious driving offence

AAMI

1

0

ALLIANZ

2

1

GIO

3

0

NRMA

13

14

QBE

0

0

Total

19

15

Table: Claims declined for other reasons (Other includes injury not existent, or not covered under the legislation)

Insurer

2020 Number of claims declined for other reasons (Other includes injury not existent, or not covered under the legislation)

2019 Number of claims declined for other reasons (Other includes injury not existent, or not covered under the legislation)

AAMI

2

0

ALLIANZ

3

0

GIO

2

0

NRMA

3

9

QBE

2

2

Total

12

11

How long did it take to receive treatment and care benefits?

Receiving treatment immediately after an accident is critical for making a full recovery. That is why insurers cover initial medical expenses for most people before they lodge a formal claim. This is when customers access treatment and care services after notifying the insurer, but before lodging a formal claim.

74% of injured people received ‘pre-claim support’ in 2020, with a further 21% accessing treatment and care services within the first month after lodging a claim. This result is an improvement on 2019, where 73% of customers accessed treatment and care benefits prior to formally lodging a claim.

Table – CHART 3: Time it takes to receive treatment and care benefits (in weeks)

Insurer

Year

Before Lodgement

0 to 4 weeks

5 to 13 weeks

14 to 26 weeks

Number of claims

AAMI

2020

66%

29%

5%

0%

711

AAMI

2019

65%

27%

7%

1%

756

ALLIANZ

2020

79%

17%

4%

0%

1,678

ALLIANZ

2019

78%

18%

4%

0%

1,732

GIO

2020

67%

27%

5%

1%

1,402

GIO

2019

64%

27%

8%

1%

1,516

NRMA

2020

76%

19%

4%

1%

2,571

NRMA

2019

78%

17%

4%

1%

2,889

QBE

2020

76%

19%

4%

1%

1,951

QBE

2019

72%

23%

4%

1%

2,044

Total

2020

74%

21%

4%

1%

8,313

Total

2019

73%

21%

5%

1%

8,937

Some insurers cover expenses faster than others. Among the five insurers, Allianz had the highest

proportion of pre-claim treatment and care support.

*Of the total 9,935 accepted statutory benefits claims in 2020, 8,313 had treatment and care services. For 2019, of the total 11,162 accepted statutory benefits claims, 8,937 had treatment and care services.

How quickly have insurers paid income support to customers after motor accidents?

Some people need to take time off work after an accident. That is why it’s important for insurers to provide income support in the form of weekly payments to people while they are away from work. Half of customers entitled to income support payments received it within the first month of lodging a claim, with the vast majority receiving the income support payments within 13 weeks.

The sooner the insurer receives the relevant information from the customer, the sooner the insurer can begin to pay income support payment

Table – CHART 4: Time it takes to receive income support (in weeks)

Insurer

Year

0 to 4 weeks

5 to 13 weeks

14 to 26 weeks

27 to 52 weeks

Number of claims

AAMI

2020

58%

35%

6%

1%

323

AAMI

2019

41%

48%

9%

2%

278

Allianz

2020

68%

26%

5%

1%

693

Allianz

2019

63%

30%

5%

2%

723

GIO

2020

53%

40%

7%

0%

555

GIO

2019

42%

51%

6%

1%

639

NRMA

2020

50%

42%

6%

2%

1,047

NRMA

2019

44%

46%

9%

1%

1,065

QBE

2020

42%

47%

9%

2%

711

QBE

2019

45%

44%

10%

1%

787

Total

2020

53%

39%

7%

1%

3,329

Total

2019

48%

43%

8%

1%

3,492

Some insurers begin paying income support faster than others. Among the five insurers, Allianz had the highest proportion of customers who received income support within the first month of lodging a claim.

*Of the total 9,935 accepted statutory benefits claims in 2020, 3,329 had payments for loss of income. For 2019, of the total 11,162 accepted statutory benefits claims, 3,492 had payments for loss of income.

What happened when customers disagreed with the insurer’s decision?

Customers who disagree with the insurer’s decision can ask for a review. The decision will be reconsidered by the insurer’s internal review team, who did not take part in making the original decision. Insurers accepted most applications for internal reviews. However, some applications were declined because:

  • the request was submitted late and the customer did not respond to requests for reasons why it was submitted late, or
  • the insurer determined it did not have the jurisdiction to conduct an internal review of that decision.

Customers sometimes also withdraw their application for an internal review.

Table – CHART 5: Internal reviews by insurers and status (percentage)

Insurer

2020 Number of internal reviews

2019 Number of internal reviews

AAMI

256

233

ALLIANZ

437

342

GIO

465

446

NRMA

512

548

QBE

560

328

Total

2,230

1,897

Table: Percentage of claims withdrawn

Insurer

2020 Percentage of claims withdrawn

2019 Percentage of claims withdrawn

AAMI

8%

10%

ALLIANZ

4%

2%

GIO

11%

9%

NRMA

6%

8%

QBE

7%

20%

Total

7%

10%

AAMI

8%

10%

Table: 2020 Percentage of claims determined

Insurer

2020 Percentage of claims determined

2019 Percentage of claims determined

AAMI

75%

56%

ALLIANZ

86%

80%

GIO

77%

56%

NRMA

84%

84%

QBE

76%

71%

Total

80%

71%

Table: Percentage of claims in progress

Insurer

2020 Percentage of claims in progress

2019 Percentage of claims in progress

AAMI

14%

32%

ALLIANZ

9%

17%

GIO

10%

33%

NRMA

6%

5%

QBE

9%

6%

Total

9%

17%

Table: Percentage of claims declined

Insurer

2020 Percentage of claims declined

2019 Percentage of claims declined

AAMI

3%

2%

ALLIANZ

1%

1%

GIO

2%

2%

NRMA

4%

3%

QBE

8%

3%

Total

4%

2%

The number of internal review requests received by insurers depends on how many customers they have. Insurers with more customers are more likely to receive a greater number of internal review requests. By measuring insurer internal reviews per 100,000 Green Slips sold, the regulator can compare insurers’ performance regardless of how many customers they have.

Table: Internal Reviews per 100,000 Green Slips sold

Insurer

2020 year

2019 year

AAMI

51

51

ALLIANZ

45

36

GIO

50

46

NRMA

27

29

QBE

38

23

Total

39

33

Table: Internal reviews to accepted claims ratio

Insurer

2020 Internal reviews to accepted claims ratio

2019 Internal reviews to accepted claims ratio

AAMI

31%

24%

ALLIANZ

23%

17%

GIO

28%

22%

NRMA

17%

15%

QBE

23%

13%

Outcomes of resolved internal reviews

Of the total 1,778 resolved internal reviews in 2020, 76% had the initial claim decision upheld. In 2019, 71% resolved internal reviews had the decision upheld.

Table – Chart 6: Outcomes of resolved internal review by review type (%)

-

Year

Decision overturned – in favour of claimant

Decision overturned – in favour of insurer

Decision upheld

Internal reviews

Amount of weekly payments

2020

46%

11%

43%

150

Amount of weekly payments

2019

52%

8%

40%

101

Is injured person mostly at fault

2020

28%

0%

72%

166

Is injured person mostly at fault

2019

24%

0%

76%

108

Minor Injury

2020

9%

0%

91%

717

Minor Injury

2019

15%

0%

85%

642

Other review types

2020

27%

1%

72%

333

Other review types

2019

39%

1%

60%

210

Treatment and Care R&N

2020

29%

2%

69%

412

Treatment and Care R&N

2019

42%

1%

57%

287

Total

2020

22%

2%

76%

1,778

Total

2019

28%

1%

71%

1,348

Note: The figures are rounded to the nearest whole percentage.

Table – Chart 6B: Outcomes of resolved internal review by insurer (%)

-

Year

Decision overturned – in favour of claimant

Decision overturned – in favour of insurer

Decision upheld

Internal reviews

AAMI

2020

17%

3%

80%

191

AAMI

2019

23%

1%

76%

131

ALLIANZ

2020

25%

1%

74%

375

ALLIANZ

2019

29%

1%

70%

273

GIO

2020

18%

2%

80%

359

GIO

2019

23%

1%

76%

248

NRMA

2020

27%

2%

71%

429

NRMA

2019

32%

1%

67%

464

QBE

2020

19%

0%

81%

424

QBE

2019

28%

0%

72%

232

Internal review timeframes

The insurers internal review team must assess the claim within legislated timeframes.

The data shows the performance of each insurer in meeting those timeframes.

CHART 7: Internal reviews completed by timeframe %

-

Year

Within timeframe

Outside timeframe

AAMI

2020

43%

57%

AAMI

2019

34%

66%

ALLIANZ

2020

99%

1%

ALLIANZ

2019

100%

0%

GIO

2020

36%

64%

GIO

2019

30%

70%

NRMA

2020

75%

25%

NRMA

2019

29%

71%

QBE

2020

98%

2%

QBE

2019

99%

1%

Total

2020

72%

28%

Total

2019

55%

45%

Allianz and QBE have consistently completed their internal review claims within the allowable timeframes. In response to SIRA’s regulatory action, NRMA have improved their review processing times in 2020. Regulatory review of both AAMI and GIO is continuing.

Note: The time taken to review an internal review is sourced from data provided by each insurer.

Internal review timeframes by dispute type

There are three types of internal reviews:

1. Merit review (e.g. the amount of weekly benefits)

2. Medical assessment (e.g. permanent impairment, minor injury or treatment and care)

3. Miscellaneous claims assessment (e.g. whether the claimant was mostly at fault).

For most internal reviews, the insurer must provide their internal review decision within 14 days of receiving the request for internal review. However, there are some medical assessment and miscellaneous claims assessment matters where this timeframe is extended to 21 days.

The maximum timeframe for all internal reviews is 28 days if further information is required.

CHART 7B: Internal review duration shown by dispute type and timeframe (days)

Table: Internal review decisions with 14-day timeframes for a decision

-

Year

Medical Assessment (days taken)

Merit review (days taken)

Miscellaneous claims assessment (days taken)

Timeframe for decision

AAMI

2020

44

37

29

14

AAMI

2019

34

27

37

14

ALLIANZ

2020

14

15

15

14

ALLIANZ

2019

12

12

12

14

GIO

2020

45

42

40

14

GIO

2019

33

33

32

14

NRMA

2020

19

17

12

14

NRMA

2019

33

38

42

14

QBE

2020

15

16

16

14

QBE

2019

15

15

16

14

Table: Internal review decisions with 21-day timeframe for a decision

-

Year

Medical Assessment (days taken)

Miscellaneous claims assessment (days taken)

Timeframe for decision (days taken)

AAMI

2020

36

31

21

AAMI

2019

38

43

21

ALLIANZ

2020

20

20

21

ALLIANZ

2019

15

18

21

GIO

2020

42

37

21

GIO

2019

41

36

21

NRMA

2020

24

21

21

NRMA

2019

38

36

21

QBE

2020

23

22

21

QBE

2019

21

21

21

What if customers still disagreed with the reviewed decision by the insurer?

If the customer continues to disagree with the insurer about their claim after the insurer internal review, customers may apply to the Dispute Resolution Service (DRS) for an independent determination of the dispute. Most applications require an internal review by the insurer prior to applying to DRS.

DRS can assist in resolving disputes in one of two ways:

  • Facilitate the formal resolution of issues in dispute between insurer and customer.
  • Arrange an independent and binding decision by an expert decision-maker.

Sometimes DRS applications can be:

  • Declined by DRS if they are submitted outside the timeframes set by the legislation or the matter is outside the jurisdiction of DRS,
  • Withdrawn by the customer, or
  • Settled between the customer and insurer outside the DRS formal process.

Table – Chart 8: Dispute Resolution Cases by Insurer and Status (%) *

Insurer

Number of DRS reviews

Percentage of DRS Reviews in Progress

Percentage of Withdrawn DRS reviews

Percentage of declined DRS reviews

Percentage of Determined DRS reviews

Percentage of Other *** DRS reviews

DRS Disputes per 100,000 Green Slips sold**

AAMI

512

41%

9%

3%

42%

5%

39

ALLIANZ

1,064

34%

11%

4%

44%

7%

40

GIO

1,195

40%

11%

3%

41%

5%

44

NRMA

1,391

29%

14%

5%

47%

5%

26

QBE

1,036

43%

11%

3%

38%

5%

25

Total

5,198

36%

11%

4%

43%

6%

32

Table – Chart 9: Outcomes of resolved DRS reviews*

-

Insurer decision overturned

Insurer decision Upheld

Other

Minor Injury

33%

67%

0%

Treatment and care R&N

46%

54%

0%

Is the injured person mostly at fault

67%

33%

0%

Amount of weekly payments

51%

49%

0%

All other dispute types

45%

47%

8%

Total

41%

58%

1%

*Data from 1 Dec 2017 to 30 September 2020.

**The number of dispute resolution cases received by DRS depends on how many customers individual insurers have. Insurers with more customers are more likely to receive a greater number of dispute resolution applications. By measuring dispute resolution cases per 100,000 Green Slips sold, the regulator can compare insurers’ performance regardless of how many customers they have.

***Open in error, invalid or dismissed disputes.

Compliments and complaints

SIRA closely monitors the compliments and complaints it receives about insurers. Compliments help identify best practice in how insurers manage claims, while complaints may highlight problems with insurers’ conduct which could require further investigation.

How SIRA handles complaints

Customers can lodge complaints through any of SIRA’s channels. Non-complex complaints are handled by SIRA’s CTP Assist service and usually take less than two working days to close*.  Complex complaints are referred to SIRA’s complaints handling experts and take more than two working days to close, depending on their complexity. Potential cases of insurer misconduct are escalated to SIRA’s supervision teams for further investigation and possible regulatory action.

Customers who are unhappy with the outcome of SIRA’s review can resubmit their complaint for further consideration. If customers disagree with how SIRA handled their complaint, they can contact the NSW Ombudsman for assistance.

Snapshot of resolved complaints process

Customers are encouraged to talk to their insurer in the first instance; insurers have their own complaints handling process.

  • SIRA received 640 complaints. 528 complaints were triaged into the non-complex complaints’ category, and 112 were triaged into the complex complaint category.
  • Non-complex complaints are typically resolved within two days. 450 non-complex complaints were resolved.
  • 78 non-complex complaints were escalated to complex.
  • Complex complaints take >2 days on average to resolve. 193 complex complaints were resolved.
  • 85 complex complaints were referred to SIRA’s supervision teams.

Any customers dissatisfied with SIRA’s handling of their complaint can contact the NSW Ombudsman.

This information was collected from 1 October 2019 to 30 September 2020.

How many compliments and complaints did SIRA receive?

Table: Compliments

Insurer

Number of compliments received

ALL INSURERS

178

AAMI

15

ALLIANZ

50

GIO

31

NRMA

47

QBE

35

Compliments per 100,000 Green Slips

The number of compliments and complaints insurers receive depends on how many customers they have. Insurers with more customers will receive more compliments and complaints, and vice versa. Therefore, by measuring compliments and complaints per 100,000 Green Slips sold, the regulator can compare insurers’ performance regardless of how many customers they have.

Table: Number of compliments per 100,00 Green Slips

Insurer

Number of compliments received per 100,000 Green Slips

ALL INSURERS

3

AAMI

3

ALLIANZ

5

GIO

3

NRMA

2

QBE

2

Table: Complaints

Insurer

Number of complaints received

ALL INSURERS

640

AAMI

66

ALLIANZ

69

GIO

130

NRMA

210

QBE

165

Table: Complaints per 100,000 Green Slips

Insurer

Number of complaints received per 100,000 Green Slips

ALL INSURERS

11

AAMI

13

ALLIANZ

7

GIO

14

NRMA

11

QBE

11

Who made the complaint?

  • Person injured 348
  • Lawyer 213
  • Green Slip holder 24
  • Health provider 26
  • Other 29*

This information was collected from 1 October 2019 to 30 September 2020.

*The “Other” category are complaints predominantly by SIRA staff for calls to insurers, which for various reasons, take an unnecessary long time to action.

What were the complaints about?

Table: AAMI

Type of complaint

Portion of total complaints received by AAMI which related to that type of complaint

Claims: Decisions

21%

Claims: Delays

15%

Claims: Management

42%

Claims: Service

14%

Claims: Other

3%

Policy: Purchasing

5%

Table: Allianz

Type of complaint

Portion of total complaints received by Allianz which related to that type of complaint

Claims: Decisions

28%

Claims: Delays

16%

Claims: Management

34%

Claims: Service

16%

Claims: Other

3%

Policy: Purchasing

3%

Table: GIO

Type of complaint

Portion of total complaints received by GIO which related to that type of complaint

Claims: Decisions

22%

Claims: Delays

26%

Claims: Management

23%

Claims: Service

20%

Claims: Other

4%

Policy: Purchasing

5%

Table: NRMA

Type of complaint

Portion of total complaints received by NRMA which related to that type of complaint

Claims: Decisions

17%

Claims: Delays

20%

Claims: Management

28%

Claims: Service

29%

Claims: Other

1%

Policy: Purchasing

5%

Table: QBE

Type of complaint

Portion of total complaints received by QBE which related to that type of complaint

Claims: Decisions

15%

Claims: Delays

25%

Claims: Management

31%

Claims: Service

24%

Claims: Other

3%

Policy: Purchasing

2%

Table: All insurer related complaints

Type of complaint

Portion of total complaints received by Insurers which related to that type of complaint

Claims: Decisions

19%

Claims: Delays

22%

Claims: Management

29%

Claims: Service

23%

Claims: Other

3%

Policy: Purchasing

4%

Enforcement & Prosecutions (E&P)

SIRA has continued to improve its strategies in detecting and responding to breaches of the Motor Accident legislation and guidelines. SIRA works closely with law enforcement agencies and other regulatory bodies to ensure appropriate strategies are in place to minimise risks to the CTP scheme.

The E&P team undertakes a risk-based approach to its investigations by taking into consideration the risk and harm to the scheme, claimants and policy holders and carries out appropriate regulatory enforcement action on a case by case basis.

High level approach is summarised as follows:

SIRA receives:

  • Internal SIRA referrals
  • External referrals
  • Risk-based compliance audits

Referrals received go to the E&P team. When the matter is finalised, the following options are available to E&P:

  • Education
  • Notification of breach
  • Letter of censure
  • Penalty provisions
  • Criminal prosecution and licencing withdrawal
  • Media releases

For more information about how SIRA approaches its compliance and enforcement activities, please refer to SIRA’s Compliance and Enforcement Policy.

From 1 October 2019 to 30 September 2020, 69 matters were referred to the E&P team for investigation into alleged insurer breaches of their obligations under the Motor Accidents Compensation Act 1999 (1999 Scheme) and the Motor Accident Injuries Act 2017 (2017 Scheme) and guidelines. A total of 39 matters were finalised during this period, which includes matters received prior to October 2019.

Table: Completed Investigations

Insurer

Completed Investigations

1999 Scheme

2017 Scheme

Allianz

0

0

0

AAMI

7

5

2

GIO

4

3

1

NRMA

25

5

20

QBE

3

0

3

TOTAL

39

13

26

Table: Regulatory Action

Insurer

Number

Type of Regulatory Action

1999 Scheme

2017 Scheme

Allianz

0

-

0

0

AAMI

5

Letter of censure

4

1

GIO

2

Letter of censure

1

1

NRMA

11

Notification of breach

1

10

NRMA

2

Civil penalty

2

0

NRMA

2

Letter of censure

0

2

QBE

1

Notification of breach

0

1

QBE

2

Letter of censure

0

2

TOTAL

25

 

8

17

Of those matters where an insurer breach was substantiated, the following issues were identified, and insurers subsequently notified:

  • Failure to endeavour to resolve claims in a just and expeditious manner in line with their obligations and licence conditions under the Act and Guidelines;
  • Failure to complete and notify the results of their internal reviews within timeframes stipulated under the Act and Guidelines;
  • Failure to respond or late response to a treatment and care request by the claimant or their representative;
  • Inappropriate management of CTP claims.

The other matters finalised during this period were determined to be insurer practice issues of a minor nature and they have been referred to SIRA’s insurer supervision unit for education and continued monitoring.

Glossary

Accepted claims - The total number of statutory benefit claims where liability was not declined during the first 26 weeks of the benefit entitlement period.

Claims acceptance rate - The percentage of statutory benefit claims where liability was not declined during the first 26 weeks of the benefit entitlement period. It is the total count of statutory benefit claims lodged, less declined claims, divided by total statutory benefit claims.

Claim - A claim for treatment and care or loss of income regardless of fault under the Act. It excludes early notifications (before a full claim is lodged), as well as interstate, workers compensation and compensation to relatives claims.

Complaint – An expression of dissatisfaction made to or about an organisation and related to its products, services, staff or the handling of a complaint, where a response or resolution is explicitly or implicitly expected or legally required.

Complaints received - The number of complaints that have been received in the time period.

Compliment - An expression of praise.

Declined claims - The total number of statutory benefit claims where the liability is rejected during the first 26 weeks of the benefit entitlement period.

Determined DRS dispute - A dispute which has been through the DRS process and of which a decision has been made.

Income support payments - Weekly payments to an earner who is injured as a result of a motor accident and sustains a total or partial loss of earnings as a result of the injury.

Insurer - An insurer holding an in-force licence granted under Division 9.1 of the Act.

Internal review - When requested by a person, the insurer conducts an internal review of decisions made and notifies the person of the result of the review, usually within 14 days of the request.

Internal review types:

  • Minor injury - Whether the injury caused by the motor accident is a minor injury for the purposes of the Act.
  • Reasonable and necessary treatment and care - Whether any treatment and care provided to the person is reasonable and necessary in the circumstances or relates to the injury caused by the motor accident for the purposes of section 3.24 of the Act  (Entitlement to statutory benefits for treatment and care).
  • Amount of weekly payments - Whether the amount of statutory benefits payable under section 3.4 (Statutory benefits for funeral expenses) or under Division 3.3 (Weekly payments of statutory benefits) is reasonable.
  • Was accident the fault of another - Whether the motor accident was caused mostly by the injured person. This influences a person’s entitlement to statutory benefits (sections 3.28 and 3.36 of the Act).
  • Other review types:
  • Amount of weekly payments - Whether the amount of statutory benefits payable under section 3.4 (Statutory benefits for funeral expenses) or under Division 3.3 (Weekly payments of statutory benefits) is reasonable.
  • Was accident the fault of another - Whether the motor accident was caused mostly by the injured person. This influences a person’s entitlement to statutory benefits (sections 3.28 and 3.36 of the Act).
  • Other review types:
    • accident verification
    • earning capacity impairment
    • is death or injury from a NSW accident
    • variation of weekly payments
    • weekly benefits outside Australia
    • recoverable statutory benefits
    • reduction for contribution negligence
    • serious driving offence exclusion
    • permanent impairment

Internal reviews to accepted claims ratio – the proportion of internal reviews to accepted statutory benefit claims. This will remove the influence of the insurer market share and give a comparable view across insurers.

Payments - Payment types may include income support payments, treatment, care, home/vehicle modifications or rehabilitation.

Referrals to Enforcements and Prosecutions (E&P) - Where a breach of guidelines or legislation is detected through the management of a complaint or other regulatory activity undertaken by SIRA in accordance with the SIRA compliance and enforcement policy.

Service start date - The date when treatment or care services are accessed for the first time.

Total number of policies - This figure represents the total (annual) number of policies written under the new CTP scheme with a commencement date during the reporting period. The measure represents the count of all policies, across all regions in NSW.

About the data in this publication

Claims data is primarily sourced from the Universal Claims Database (UCD) which contains information on all claims received under the NSW Motor Accidents CTP scheme, which commenced on 1 December 2017, as provided by individual licensed insurers.

SIRA uses validated data for reporting purposes. Differences to insurers’ own systems can be caused by:

  • a delay between claim records being captured in insurer system and data being submitted and processed in the UCD
  • claim records submitted by the insurer being blocked by data validation rules in the UCD because of data quality issues.

All CTP compliments and complaints data from 1 October 2019 to 30 September 2020 was collected through SIRA’s complaints and operational systems. Compliments and complaints received directly by the insurers were not included.

For more information about the statistics in this publication, contact MAIRstakeholder@sira.nsw.gov.au