CTP Insurer claims experience and customer feedback comparison - Sept 2021

The report CTP insurer claims experience and customer feedback comparison - Sept 2021 PDF, 830.76 KB - is available to download.

Why does SIRA publish insurer data?

As part of its regulatory oversight, SIRA closely 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 five key indicators of customer experience across the five CTP insurers in NSW: AAMI, Allianz, GIO, NRMA and QBE. A sixth insurer, Youi, joined the scheme from 1 December 2020. Once a significant number of claims are received by Youi, it will then also be included in this report.

The following 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 of compliments and complaints received about insurers
• the number and type of issues considered for enforcement and prosecution action

Disputes raised within the scheme are handled by the Personal Injury Commission (PIC).

This issue of the report presents data for the first three measures above, over two time periods: 1 October 2019 to 30 September 2020 (the 2020 year) and 1 October 2020 to 30 September 2021 (the 2021 year).

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. Generally, these results and the indicators measuring insurer performance remain relatively stable quarter to quarter.

How many claims did insurers accept?

Insurers accepted most claims from injured people and their families. During the 2021 year, 98.1% of claims were accepted compared to 98.4% in the 2020 year. More detail on the rejected claims is provided on the following table.

Table – CHART 1: Claims Acceptance Rates by Insurer, comparing 2021 and 2020 years

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),
• the claim did not involve a motor vehicle accident.
• the claim involved an uninsured, unregistered or unidentified vehicle

1.9% of claims were declined by insurers in the 2021 year, compared with 1.6% in the 2020 year. There were 9,823 total claims accepted in the 2021 year, down from 9,948 in the 2020 year.

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

Table: Chart 2: Total Claims rejected

Table: Claims rejected due to late lodgement

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

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

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

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

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

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.

72% of injured people received ‘pre-claim support’ in the 2021 year, with a further 23% accessing treatment and care services within the first month after lodging a claim. During the 2020 year, 74% of injured people received ‘pre-claim support’ with a further 21% accessing treatment and care within the first month of lodging a claim.

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

*Of the total 9,823 accepted statutory benefits claims in the 2021 year, 8,446 had treatment and care services. For the 2020 year, of the total 9,948 accepted statutory benefits claims, 8,313 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)

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 9,823 accepted statutory benefits claims in the 2021 year, 3,571 had payments for loss of income. For the 2020 year, of the total 9,948 accepted statutory benefits claims, 3,329 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

Table: Percentage of claims withdrawn

Table: 2020 Percentage of claims determined

Table: Percentage of claims in progress

Table: Percentage of claims declined

Table: Internal Reviews per 100 claims*

*The number of internal review requests received by insurers depends on how many claims they are managing. Insurers with more claims are more likely to receive a greater number of internal reviews. By measuring internal reviews per 100 claims, SIRA can compare insurers’ performance regardless of their market share. The base for calculating this ratio is the number of open claims at the start of the reporting period plus all claims lodged during the reporting period.

Table: Internal reviews to accepted claims ratio

Outcomes of determined internal reviews

Of the total 5,993 determined internal reviews in the 2021 year, 79% had the initial claim decision upheld. In the 2020 year, 78% determined internal reviews had the decision upheld.

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

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

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

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 in the 2021 and 2020 year.

CHART 7A: Internal reviews completed by timeframe %

In response to SIRA’s regulatory action, AAMI, GIO and NRMA have significantly improved their compliance with internal review decision timeframes, particularly in the second half of 2020.

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, threshold 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

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

Compliments and complaints

From 1 March 2021, the Independent Review Office (IRO) was established. One of the key roles of the IRO is to find solutions for people injured in a motor vehicle accident with complaints about management of their claim.

Prior to the IRO being established, SIRA undertook this function for injured people with a claim for a motor vehicle accident. SIRA continues to manage complaints relating to all other aspects of the scheme, including complaints from customers in relation to their CTP Greenslip.

SIRA closely monitors the compliments and complaints it receives about insurers, working closely with the IRO through a Memorandum of Understanding to ensure customers issues and complaints are addressed.

SIRA also collects compliments to help identify best practice by insurers, whilst the customer issues and complaints are used to address individual issues and can highlight wider problems with insurer conduct that requires investigation.

The data shown reflects the period of 1 October 2020 to 30 September 2021.

Compliments and complaints received directly by the insurers are not included in the data below.

• There were 957 complaints received about insurers in total.
  • 607 were received by the IRO
  • 350 by CTP Assist.

How many compliments and complaints about insurers were received?

Chart 8: Compliments and Complaints (1 October 2020 to 30 September 2021).

Table: Compliments

Compliments and complaints 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, SIRA can compare insurers’ performance regardless of how many customers they have.

Table: Number of compliments per 100,000 Green Slips*

Table: Complaints

Table: Complaints 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, SIRA can compare insurers’ performance regardless of how many customers they have.

** The number of complaints include those received via CTP Assist and the IRO.

Enforcement & Prosecutions (E&P)

SIRA is committed to making strong, consistent and evidence-based decisions on enforcement action.

SIRA engages with law enforcement agencies, particularly the NSW Police Force, to deter and investigate fraudulent activity in the CTP scheme. SIRA is also developing fraud detection, scanning and provider management analytics software and services to help with regulatory monitoring.

SIRA’s regulatory activities are focused on areas of highest risk. Firm and fair enforcement action is taken as needed, based on the severity of harm or potential harm, the degree of negligence, and/or the need for deterrence.

The regulatory activities outlined below are supported by SIRA’s education and support initiatives. Together, these ensure that the motor accidents scheme is fair, affordable, and effective, and achieves public outcomes.

SIRA receives information on matters for potential enforcement and prosecution action through a range of regulatory monitoring activities:

The following enforcement and prosecution options are available to SIRA:

• Education
• Notification of breach
• Letter of censure
• Penalty provisions
• Criminal prosecution and licencing withdrawal
• Publication of information on breaches or poor performance.

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

From 1 October 2020 to 30 September 2021, SIRA had 44 active matters under investigation relating to 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 16 matters were finalised during this period, which includes matters received prior to October 2020. The remaining are under investigation.  Please note that investigations may involve complex systemic issues affecting multiple claims and/or customers and may result in more than one enforcement action.

Table: Completed Investigations

Table: Regulatory Action

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 provide data to SIRA in accordance with their obligations under the Act and Guidelines.

The other matters finalised during this period were determined to be insurer practice issues of a threshold nature. For these matters, SIRA has undertaken education initiatives to improve compliance and has continued to closely supervise the insurer.

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.

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:

• Threshold injury - Whether the injury caused by the motor accident is a threshold 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:
  • 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.

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