CTP Insurer Claims Experience and Customer Feedback Comparison - State Insurance Regulatory Authority (SIRA)

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CTP Insurer Claims Experience and Customer Feedback Comparison - State Insurance Regulatory Authority (SIRA)
CTP Insurer Claims
Experience and
Customer Feedback
Comparison
30 September 2020

                    State Insurance
                    Regulatory
                    Authority (SIRA)

                                       1
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 beneft from knowing what
to expect from the insurer managing their claim.

In this report, SIRA compares six key indicators of customer experience across the fve 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 benefts claims accepted by insurers
  • how quickly insurers pay statutory benefts
  • 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 frst 3 measures above, over two time periods:
1 October 2018 - 30 September 2019 and 1 October 2019 - 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 beneft as SIRA continues to improve and expand its data collection and
reporting capability.

                                                                                                           2
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 page.

 CHART 1: Claims* acceptance rates (%)

          % Accepted           % Declined                                                    Total claims
                                                                                              accepted
          2020
AAMI

                                            98.0%                                    2.0%      832
           2019                             99.4%                                   0.6%       955
ALLIANZ

          2020                              97.5%                                    2.5%      1,924
           2019                             98.2%                                    1.8%      2,050

          2020                              97.7%                                    2.3%      1,682
GIO

           2019                             99.4%                                   0.6%       2,018

          2020
NRMA

                                            98.0%                                    2.0%      3,079
           2019                             97.4%                                    2.6%      3,557

          2020                              99.7%                                    0.3%      2,418
QBE

           2019                             99.8%                                    0.2%      2,582

          2020
TOTAL

                                            98.3%                                    1.7%      9,935
           2019                             98.6%                                    1.4%      11,162

                  0%              20%               40%   60%            80%            100%

 * Statutory benefts claims.

                                                                                                            3
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 related to a serious driving ofence.
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.

CHART 2: Reasons why claims* were declined

Year ending 30 September 2020

                AAMI                        ALLIANZ                                     GIO                        NRMA                    QBE

                2                                     3                                 2                              3
                                                 2                                  3
      1                                                                     2                                13                    2
                                 6
  1                                    9
                                                               22       4
                                                                                              21
                                                                                                         5                 36

      4                                                                         7                                                                    5
                                                                                                              5
                         3                   13

 Rejected claims: 17                  Rejected claims: 49               Rejected claims: 39              Rejected claims: 62      Rejected claims: 7

Year ending 30 September 2019

                AAMI                        ALLIANZ                                     GIO                        NRMA                    QBE

                                                          1                             1                          9
            1                                5
                                                              11                                         14                       2                  2

                                                                                                                           46
                                                                        5                     7          6
                                                                                                          4

                             5                   20                                                               16                   1         1

 Rejected claims: 6                   Rejected claims: 37               Rejected claims: 13              Rejected claims: 95      Rejected claims: 6

Totals 2020 vs 2019

   TOTAL 2020                              TOTAL 2019                                              Late claim (lodged >90 days after accident)

                    12                                11
                                                                                                   Insufcient information provided to insurer
       19                                   15
                                                                                                   Claim did not involve a motor vehicle accident
                                      12
 17                                                                71
                                 90                                                                Claim involved an uninsured, unregistered or
                                       26                                                          unidentifed vehicle
      26

                10                                    22                                           Claim related to a serious driving ofence

Rejected claims: 174                  Rejected claims: 157                                         Other**

* Excludes claims which were declined because customers were covered by other scheme/insurer.
** Includes: injury non-existent, or not covered under the legislation.

                                                                                                                                                         4
How long did it take to receive
          treatment and care benefts?
 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 frst month after lodging a claim. This result is an improvement on 2019, where
 73% of customers accessed treatment and care benefts prior to formally lodging a claim.

 CHART 3: Time it takes to receive treatment and care benefts (in weeks)

          Before Lodgement            0-4 weeks             5-13 weeks            14-26 weeks
                                                                                                                                            Claims*
          2020                              66%                                                              29%              5%                711
AAMI

           2019                             65%                                                              27%          7%       1%           756

                                                                                                                         16.8%
ALLIANZ

          2020                              79%                                                              17%             4%                 1,678

           2019                             78%                                                              18%              4%                1,732

          2020                              67%                                                              27%             5% 1%              1,402
GIO

           2019                             64%                                                              27%           8%      1%           1,516

          2020                              76%                                                              19%             4% 1%              2,571
NRMA

           2019                             78%                                                              17%             4% 1%              2,889

          2020                              76%                                                              19%             4% 1%              1,951
QBE

           2019                             72%                                                              23%             4% 1%              2,044

          2020                              74%                                                              21%             4% 1%              8,313
TOTAL

           2019                             73%                                                              21%             5% 1%              8,937

               0%                  20%                     40%                    60%                    80%                   100%

 Some insurers cover expenses faster than others. Among the fve insurers, Allianz had the highest
 proportion of pre-claim treatment and care support.

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

                                                                                                                                                        5
How quickly did insurers pay income support
          to customers after motor accidents?

 Some people need to take time of 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 frst 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 payments.

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

          0-4 weeks         5-13 weeks              14-26 weeks               27-52 weeks
                                                                                                                                           Claims*

          2020                              58%                                            35%                                6%     1%         323
AAMI

           2019                             41%                                            48%                          9%           2%         278

                                                                                                                        16.8%5.2
ALLIANZ

          2020                              68%                                                  26%                           5%    1%         693

           2019                             63%                                            30%                                5%     2%         723

                                                                                                                        6.7

          2020                              53%                                            40%                                7%                555
GIO

           2019                             42%                                            51%                                6%     1%         639

                                                                                                                           5

          2020                              50%                                            42%                                6%     2%         1,047
NRMA

           2019                             44%                                            46%                           9%          1%         1,065

                                                                                                                           4

          2020                              42%                                            47%                          9%           2%         711
QBE

           2019                             45%                                            44%                          10%          1%         787

                                                                                                                         5

          2020                              53%                                            39%                             7%        1%         3,329
TOTAL

           2019                             48%                                            43%                            8%         1%         3,492

                  0%                 20%                    40%                   60%                    80%                       100%

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

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

                                                                                                                                                        6
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.
CHART 5: Internal reviews by insurers and status (%)

Year ending 30 September 2020
   AAMI 256          ALLIANZ 437                                    GIO 465                       NRMA 512                           QBE 560

                 3   8                        14                           2   11                          4     6                        8       7
                                                   9                                                                     6                              9
                          14                                                        10

       75                                                           77
                                         86                                                            84                                 76

Internal reviews per 100,000 Green Slips*
       AAMI 51                       Allianz 45                          GIO 50                       NRMA 27                            QBE 38

Year ending 30 September 2019
   AAMI 233          ALLIANZ 342                                    GIO 446                       NRMA 548                           QBE 328

                 2   10                       12                           2   9                           3      8                           3
                                                    17                                                                   5                            20

                                                                                                                                                            6
                              32                                                     33
 56                                                            56

                                                                                                                                    71
                                    80                                                                84

Internal reviews per 100,000 Green Slips*
        AAMI 51                      Allianz 36                          GIO 46                       NRMA 29                            QBE 23

Totals 2020 vs 2019                                                                      Internal reviews to accepted claims ratio
   TOTAL 2020                      TOTAL 2019                                                                                      2020               2019
                                                                                          32
                 4   7                         2   10
                                                                                          28
                          9
                                                         17                               24

                                                                                          20

                                                                                          16
                                    71                          % Withdrawn               12
            80
                                                                % In Progress              8
      Total 2,230                  Total 1,897                                             4
                                                                % Determined
Internal reviews per 100,000 Green Slips*
                                                                                           0
        2020: 39                      2019: 33                  % Declined                     AAMI            Allianz       GIO   NRMA           QBE

*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.                                                                         7
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.

 CHART 6: Outcomes of resolved internal review by review type (%)

         % Decision overturned - in favour of claimant              % Decision overturned - in favour of insurer   % Decision upheld
                                                                                                                              Internal reviews
Amount of

payments

                   2020          46%                                              11%                               43%            150
 Weekly

                   2019          52%                                                    8%                          40%            101
person mostly

                   2020          28%                                                                                72%            166
  Is injured

   at fault?

                   2019          24%                                                                                76%            108

                   2020          9%                                                                                 91%            717
    Minor
    Injury

                   2019          15%                                                                                85%            642
    Other review

                   2020          27%                     1%                                                         72%            333
       types

                   2019          39%                               1%                                               60%            210
    Treatment &
     Care R&N

                   2020          29%                          2%                                                    69%            412
                   2019          42%                                     1%                                         57%            287

                   2020          22%                2%                                                              76%            1,778
          Total

                   2019          28%                      1%                                                        71%            1,348
                          0%                 20%                   40%                   60%               80%             100%
 Note: Figures are rounded to the nearest whole percentage

 CHART 6B: Outcomes of resolved internal reviews by insurer %

 Year ending 30 September 2020
         % Decision overturned - in favour of claimant              % Decision overturned - in favour of insurer   % Decision upheld

             AAMI 191                  ALLIANZ 375                        GIO 359               NRMA 429                   QBE 424

                   3                            1                             2                       2
          17                                                         18                                                19
                                       25
                                                                                               27

                                                         74                                                   71
                          80                                                       80                                             81

 Year ending 30 September 2019
             AAMI 131                 ALLIANZ 273                        GIO 248                NRMA 464                   QBE 232

                    1                           1                             1                        1
         23                                                          23                                               28
                                       29                                                      32

                                                         70                                                   67
                                                                                                                                       72
                           76                                                       76

                                                                                                                                            8
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 %

          % Within timeframe          % Outside timeframe

           2020             43%                                                                         57%
AAMI

           2019             34%                                                                         66%
ALLIANZ

           2020             99%                                                                          1%

           2019             100%

           2020             36%                                                                         64%
GIO

           2019             30%                                                                         70%

           2020             75%                                                                         25%
NRMA

           2019             29%                                                                         71%

           2020             98%                                                                         2%
QBE

           2019             99%                                                                          1%

           2020             72%                                                                         28%
TOTAL

           2019             55%                                                                         45%

                  0%                   20%                       40%                       60%    80%     100%

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

                                                                                                                 9
Internal review timeframes by dispute type

There are three types of internal reviews:
1.   Merit review (eg the amount of weekly benefts)
2. Medical assessment (eg permanent impairment, minor injury or treatment and care)
3. Miscellaneous claims assessment (eg 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)

     2020          2019             14 days timeframe
     50

     45

     40

     35

     30

     25

     20

     15

     10

     5

     0
          AAMI ALLIANZ GIO      NRMA QBE             AAMI ALLIANZ GIO   NRMA QBE              AAMI ALLIANZ GIO        NRMA QBE

                   Medical assessment                         Merit review                      Miscellaneous claims assessment

     2020          2019             21 days timeframe
     50

     45

     40

     35

     30

     25

     20

     15

     10

      5

      0
            AAMI      ALLIANZ       GIO       NRMA      QBE                  AAMI     ALLIANZ        GIO       NRMA        QBE

                                Medical assessment                                  Miscellaneous claims assessment

                                                                                                                                  10
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.

  CHART 8: Dispute resolution cases by insurer and status (%)*

       AAMI 512              ALLIANZ 1,064                GIO 1,195             NRMA 1,391               QBE 1,036               TOTAL 5,198

            5                        7                       5                       5                         5                         6
                                              34                                             29
                                                                    40                                                                                36
                        41                                                                                            43
   42                                                41                                                38
                              44                                               47                                               43
                                                                                             14
                                             11                                                               3 11                               11
            3 9                          4                   3 11                        5                                                   4

  DRS reviews per 100,000 Green Slips**
       AAMI 39                 Allianz 40                  GIO 44               NRMA 26                     QBE 25                TOTAL 32

        % In Progress              % Withdrawn         % Declined              % Determined            Other***

  CHART 9: Outcomes of resolved DRS review* (%)

        % Insurer decision overturned              % Insurer decision upheld             % Other

       Minor injury                  33%                                             67%                                             1

  Treatment and
    care R&N                         46%                                             54%                                                         41

Is injured person                                                                                                          58
                                     67%                                             33%
  mostly at fault
   Amount of
                                     51%                                             49%
weekly payments
         All other
                                     45%                                             47%               8%
      dispute types

                Total                41%                                             58%               1%                  TOTAL 2,220

                        0%            20%            40%                 60%             80%                100%

  *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.

                                                                                                                                                           11
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 the insurer handling their claim in the frst instance; insurers have
their own complaints handling process.

                                                                       Non-complex
                                                                        complaints

                                         528                        Typically resolved
                                                                     within two days
                                                                           450 closed

                    640 complaints                                                 78 non-complex complaints
                       received                                                    were escalated to complex

                                                                            Complex
                                                                           complaints
                                          112
                                                                       Take >2 days
                                                                        to resolve
                                                                           193 closed

                                                                                   85 complex complaints
                                                                                   were referred

                                                                    Referral to SIRA’s
                                                                    supervision teams

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

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

* Where SIRA reviews a complaint and provides an outcome.
                                                                                                               12
How many compliments and complaints
    about insurers did SIRA receive?
CHART 10: Compliments & complaints (1 October 2019 - 30 September 2020)

Compliments
                                                                                                    Compliments
          TOTAL 178                                                                                 per 100,000 Green Slips*

             AAMI 15                                                                                TOTAL 3
                                                                                                    AAMI 3
        ALLIANZ 50
                                                                                                    ALLIANZ 5
              GIO 31                                                                                GIO 3
                                                                                                    NRMA 2
           NRMA 47
                                                                                                    QBE 2

             QBE 35

                        0               45               90                135            180

Complaints
                                                                                                    Complaints
         TOTAL 640                                                                                  per 100,000 Green Slips*

            AAMI 66                                                                                 TOTAL 11
                                                                                                    AAMI 13
        ALLIANZ 69
                                                                                                    ALLIANZ 7

             GIO 130                                                                                GIO 14
                                                                                                    NRMA 11
          NRMA 210                                                                                  QBE 11

            QBE 165

                        0               175             350                525            700

Who made the complaint?

 Person injured 348

         Lawyer 213

Green Slip holder 24

 Health provider 26

          Other** 29

                        0               100              200               300            400

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

* The number of compliments and complaints insurers receive depends on how many customers they have. Insurers with more customers are
  more likely to receive a higher number of compliments and complaints. By measuring compliments and complaints per 100,000 Green Slips
  sold, the regulator can compare insurers’ performance regardless of how many customers they have.
**The “Other” category are complaints predominantly by SIRA staf for calls to insurers which for various reasons take an unnecessary long
  time to action.
                                                                                                                                            13
What were the complaints about?

CHART 11: Complaints categories (%)

AAMI                                                                       ALLIANZ

                3 5                                                                    3 3
                            21                Claims: Decisions                                                Claims: Decisions
      14                                                                        16                   28
                                              Claims: Delays                                                   Claims: Delays

                                              Claims: Management                                               Claims: Management
                                              Claims: Service                                                  Claims: Service
                                    15
                                              Claims: Other                                                    Claims: Other

                                              Policy Purchasing                                      16        Policy Purchasing
                                                                                 34
            42

GIO                                                                        NRMA

                     5                                                                1 5
                4                             Claims: Decisions                                 17             Claims: Decisions
                               22
                                              Claims: Delays                                                   Claims: Delays
   20
                                              Claims: Management           29                                  Claims: Management

                                              Claims: Service                                                  Claims: Service
                                                                                                          20
                                              Claims: Other                                                    Claims: Other
                                 26           Policy Purchasing                                                Policy Purchasing
           23
                                                                                           28

QBE                                                                        ALL INSURER RELATED COMPLAINTS

                    3 2                                                               3 4
                          15                  Claims: Decisions                                 19             Claims: Decisions

                                              Claims: Delays                                                   Claims: Delays
    24
                                                                            23
                                              Claims: Management                                               Claims: Management
                                              Claims: Service                                                  Claims: Service
                                    25
                                              Claims: Other                                               22   Claims: Other

                                              Policy Purchasing                                                Policy Purchasing

                31                                                                    29

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

                                                                                                                                    14
Enforcement and 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 considering 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:

                                                                                              Risk-based
               Internal SIRA referrals                 External referrals
                                                                                           compliance audits

                                                      Enforcement and
          Matters fnalised                                                                    Referrals received
                                                     Prosecutions Team

                                                                                             Criminal
                        Notifcation               Letter of           Penalty              prosecution
    Education                                                                                                Media releases
                         of breach                censure            provisions            & licensing
                                                                                           withdrawal

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 fnalised during this period, which includes matters received prior to October 2019.

          Completed         1999         2017                   Regulatory                               1999       2017
          Investigations    Scheme       Scheme                 Action                                   Scheme     Scheme
ALLIANZ   —                —             —            ALLIANZ   —                                        —          —
AAMI      7                5             2            AAMI      5 Letter of censure                      4          1
GIO       4                3             1            GIO       2 Letter of censure                      1          1
NRMA      25               5             20           NRMA      11 Notifcation of breach                 1          10
                                                                2 Civil penalty                          2          —
                                                                2 Letter of censure                      —          2
QBE       3                —             3            QBE       1 Notifcation of breach                  —          1
                                                                2 Letter of censure                      —          2
TOTAL     39               13            26           TOTAL     25                                       8          17

Of those matters where an insurer breach was substantiated, the following issues were identifed, and
insurers subsequently notifed:
•   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 fnalised 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.
                                                                                                                              15
Glossary

Accepted claims - The total number of statutory             Internal review types:
beneft claims where liability was not declined during
the frst 26 weeks of the beneft entitlement period.         • Minor injury - Whether the injury caused by the
                                                              motor accident is a minor injury for the purposes of
Claims acceptance rate - The percentage of statutory          the Act.
beneft claims where liability was not declined during
the frst 26 weeks of the beneft entitlement period. It      • Amount of weekly payments - Whether the amount
is the total count of statutory beneft claims lodged,         of statutory benefts payable under section 3.4
less declined claims, divided by total statutory beneft       (Statutory benefts for funeral expenses) or under
claims.                                                       Division 3.3 (Weekly payments of statutory benefts)
                                                              is reasonable.
Claim - A claim for treatment and care or loss of
income regardless of fault under the Act. It excludes       • Reasonable and necessary treatment and care -
early notifcations (before a full claim is lodged),           Whether any treatment and care provided to the
as well as interstate, workers compensation and               person is reasonable and necessary in the given
compensation to relatives claims.                             circumstances or whether it relates to the injury
                                                              caused by the motor accident for the purposes of
Complaint – An expression of dissatisfaction made to          section 3.24 of the Act (Entitlement to statutory
or about an organisation and related to its products,         benefts for treatment and care).
services, staf or the handling of a complaint, where
a response or resolution is explicitly or implicitly        • Was the accident the fault of another - Whether the
expected or legally required.                                 motor accident was caused mostly by the injured
                                                              person. This infuences a person’s entitlement to
Complaints received - The number of complaints that           statutory benefts (sections 3.28 and 3.36 of the Act).
have been received in the time period.
                                                            • Other insurer internal review types:
Compliment - An expression of praise.                           • accident verifcation
                                                                • earning capacity impairment
Declined claims - The total number of statutory beneft          • whether death or injury from a NSW accident
claims where the liability is rejected during the frst 26       • variation of weekly payments
weeks of the beneft entitlement period.                         • weekly benefts outside Australia
                                                                • recoverable statutory benefts
Determined DRS dispute - A dispute which has been               • reduction for contribution negligence
through the DRS process and of which a decision has             • serious driving ofence exclusion
been made.                                                      • permanent impairment

Dispute Resolution Service (DRS) - A service                Internal reviews to accepted claims ratio - the
established under Division 7 of the Act to provide a        proportion of internal reviews to accepted statutory
timely, independent, fair and cost efective system for      beneft claims. This will remove the infuence of the
the resolution of disputes.                                 insurer market share and give a comparable view
                                                            across insurers.
Income support payments - Weekly payments to an
earner who is injured as a result of a motor accident,      Payments - Payment types may include income
and sustains a total or partial loss of earnings as a       support payments, treatment, care, home/vehicle
result of the injury.                                       modifcations or rehabilitation.

Insurer - An insurer holding an in-force licence granted    Referrals to Enforcement and Prosecutions (E&P) -
under Division 9.1 of the Act.                              Where a breach of guidelines or legislation is detected
                                                            through the management of a complaint or other
Internal review - When requested by a person, the           regulatory activity undertaken by SIRA in accordance
insurer conducts an internal review of decisions made       with the SIRA compliance and enforcement policy.
and notifes the person of the result of the review,
usually within 14 days of the request.                      Service start date - The date when treatment or care
                                                            services are accessed for the frst time.

                                                            Total number of policies - This fgure 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.

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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. Diferences 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

Disclaimer
This publication may contain information that relates to the regulation of workers compensation insurance, motor
accident third party (CTP) insurance and home building compensation in NSW. It may include details of some of your
obligations under the various schemes that the State Insurance Regulatory Authority (SIRA) administers. However, to
ensure you comply with your legal obligations you must refer to the appropriate legislation as currently in force. Up
to date legislation can be found at the NSW Legislation website www.legislation.nsw.gov.au. This publication does not
represent a comprehensive statement of the law as it applies to particular problems or to individuals, or as a substitute
for legal advice. You should seek independent legal advice if you need assistance on the application of the law to your
situation. This material may be displayed, printed and reproduced without amendment for personal, in-house or non-
commercial use.

While reasonable care has been taken in preparing this document, the State Insurance Regulatory Authority (SIRA)
makes no warranties of any kind about its accuracy, currency or suitability for any particular purpose. SIRA disclaims
liability for any kind of loss or damages arising from, or in connection with, the use of any information in this document.

Catalogue no. SIRA09023
State Insurance Regulatory Authority
2-24 Rawson Place, Sydney NSW 2000
General phone enquiries 13 10 50 Website www.sira.nsw.gov.au
©Copyright State Insurance Regulatory Authority NSW 0619

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