How to lodge an eligibility dispute with icare lifetime care

If you're not happy with a decision made about your eligibility for participation in the Lifetime Care and Support Scheme, you can dispute the decision, which will be resolved through a formal dispute process.

A dispute occurs when someone disagrees with a decision we’ve made about your eligibility for either ‘interim participation’ (for an initial two years) or ‘lifetime participation’ (for life) in the Lifetime Care and Support Scheme.

Eligibility for participation in the Scheme can be disputed on either medical or legal grounds.

You can lodge a dispute if you disagree with our decision about whether your injury meets the criteria specified in the Lifetime Care and Support Guidelines for participation in the Scheme (medical eligibility).

We have an independent assessment panel of medical and healthcare professionals who’ll resolve the dispute about whether your injury meets the criteria for participation in the Scheme.

You can also lodge a dispute if you disagree with our decision about whether your injury is a ‘motor accident injury’ which is whether it meets the legal definition of a motor accident (legal eligibility).

We use an independent assessment panel of legal professionals who’ll resolve the dispute about whether your accident meets the legal definition of a motor accident.

How decisions about eligibility are made

We’ll make a decision about your eligibility based on the information provided in your application form, and additional information provided in other reports we receive such as police and ambulance reports and hospital records.

To determine eligibility, we assess the information to see if you meet the criteria in our Guidelines.

The process is the same for both interim participation and lifetime participation.

Learn more about what we cover for motor accident injuries.

What you need to know about lodging a dispute about eligibility

  1. Disputing our eligibility decision
    It’s okay to disagree with a decision we’ve made - it won’t change the way we provide support to you.
  2. Disputes must be lodged within 6 of the decision we have made
    Disputes need to be lodged in writing, within six months of when you received the decision.
  3. Who can lodge your dispute about eligibility

    An eligibility dispute can be lodged either by you, your representative, or a relevant CTP insurer. A representative can include a family member, solicitor or advocate.

  4. We can help you lodge your dispute
    If you need help to lodge your dispute, we have a support and advocacy service that can assist you to navigate our dispute process.  See our advocacy page for more information on accessing this service.
  5. Dispute assessment process
    Once we’ve received your dispute, it will be assessed by either an independent assessment panel of dispute assessors who are experienced medical and health professionals (eligibility dispute) or a panel of claims assessors who are experienced legal professionals  (motor accident injury dispute).
  6. Providing information to the panel

    You can provide additional information to the panel throughout the process. It’s important to make sure the panel has access to the relevant information as early as possible.

  7. Receiving your dispute outcome
    Once a decision has been made, you’ll be notified of the outcome in writing with a certificate outlining the panel’s reasons.
  8. Challenging your dispute outcome

    For an eligibility dispute, if you don’t agree with the outcome, you have the option to request a review of the assessment panel’s decision.

    For a motor accident injury dispute, the decision is legally binding and there is no option in our legislation to appeal this decision.

    Disputes about eligibility

  • What disputing your eligibility means

    To be accepted as a participant in the Scheme, you must have been severely injured in a motor accident in NSW.

    Severe injuries that may be eligible for the Scheme include:

    • Spinal cord injury
    • Brain injury
    • Amputations
    • Burns
    • Permanent blindness.

    Learn more about what we cover for motor accident injuries. A dispute occurs when you (or another party) disagrees with our decision about whether your injury meets the criteria in the Lifetime Care and Support Guidelines.

    This is a medical dispute which will be assessed by a panel of medical or other health professionals.

  • Who can lodge an eligibility dispute
    A dispute can be lodged either by you, your representative, or an insurer. A representative can include a family member, solicitor or advocate.
  • How to lodge your injury eligibility dispute

    A dispute must be lodged in writing – in a letter or email to us, explaining why you disagree with the decision.

    You should include why you think you meet (or do not meet) the injury criteria in our Guidelines.

    Your dispute needs to be lodged within six months of receiving a decision from us.

    To find out more, contact us.

    We also have a support and advocacy service that can assist you to navigate our dispute process. See our advocacy page for more information on accessing this service.

  • Who assesses your dispute

    We'll appoint an assessment panel of three independent assessors to resolve the dispute. None of the assessors will have assessed or treated you before.

    All dispute assessors are medical and health professionals and have extensive experience assessing and treating people with severe injuries.

  • How the panel make their decision

    Each panel member is sent all the relevant information about the dispute.

    The panel then decides how to assess the dispute.

    They may decide to assess you and talk to the people involved in your life (such as family members or treating health team).

    Once the assessment has been completed, the panel will jointly make a decision about the dispute.

    This decision is legally binding, which means you and icare lifetime care have to accept the decision. You are able to request a review of this decision, based on certain grounds in the legislation.

  • Providing information to the panel

    You or your representative can give information to the panel.

    This should be in writing and sent to icare lifetime care Assessment Review Team.

    It’s important to provide any relevant information as soon as possible to ensure the panel reviews it, as it may impact how the panel assesses the dispute.

    We’ll send the information to the panel and to any other parties involved in the dispute (for example, an insurer).

    You’ll also be sent a copy of any information provided by another party.

  • Length of dispute process

    Disputes about eligibility may take several months to resolve.

    This is because of the time required to gather information and to complete assessments to ensure the right decision is made. We’ll keep you informed throughout the process.

  • What happens next

    You’ll receive the decision in a written certificate outlining the panel’s reasons.

    It will be sent to you and to icare lifetime care at the same time.

    This decision is legally binding, and can only be reviewed on certain grounds.

    For details see below how to review an Assessment Panel’s decision about Eligibility.

    For more information, contact us.

    Requesting a review of an assessment panel's decision

  • Reasons you might ask for a review
    You can only apply for a review if one or more of the following applies:
    • There has been a change in your condition, being a change that occurred or that first became apparent after the dispute was referred to the Assessment Panel and that change is capable of having a material effect on the determination.
    • There is additional relevant information about your injury, being information that was not available, or could not reasonably have been obtained, before the dispute was referred to the panel and that information is capable of having a material effect on the determination.
    • The decision was not made in accordance with our Guidelines.
    • The decision is demonstrably incorrect in a material respect.
  • How to lodge an application for a review

    You or the insurer can lodge a review application within six months of receiving the assessment panel’s decision.

    The application must be in writing (letter or email) to us and must include:

    • Your name, address, contact details and the date of the panel’s decision
    • Detailed reasons why the review is being requested and how it relates to the grounds listed above
    • Any other relevant information or reports in support of your application.
  • Next steps after you request a review

    We’ll provide a copy to the other party (or parties) to the dispute, if any.

    The other party then has 20 days to make any submissions on the application.

    The application, any submissions received in response, and all documents will be considered in determining whether the application should be referred to a review panel. This decision will be made within 10 days, during which time you or any other party may be contacted for additional information.

    Within five days of the decision being made, you and the other party will be advised as to whether the application will be referred to a review panel, or whether it has been rejected. Written reasons will be provided.

  • Who is on the review panel

    If the review application is accepted, a review panel of three suitable dispute assessors from our list of approved assessors will be convened as soon as possible. 

    The panel will not include any of the assessors who were on the original assessment panel.

    You’ll be advised of the details of the review panel. Within 10 days, you (or the other party) can request different assessors if you think those chosen are not suitable.

    If so, the other party will be invited to make submissions, and if necessary or appropriate, different assessors will be allocated to the panel.

    A panel chairperson will then be appointed, and all three assessors will be sent all the information which was before the assessment panel, and all documentation received since that decision was made.

    The panel’s initial meeting will be held as soon as possible after the panel is convened (within 30 days).

  • How the review panel will assess your dispute

    The review panel will determine how it will conduct the assessment, but it must comply with the Lifetime Care and Support Scheme Guidelines.

    The review panel will consider all aspects of the dispute afresh, and will decide whether:

    • Another clinical examination is required, or if the assessment can be made using the existing documentation
    • Any additional information is required
    • Any additional meetings are required

    You may be asked to comply with any reasonable request from the review panel, including undergoing a clinical examination if necessary.

    The review panel will either confirm or revoke the decision of the assessment panel.

  • Length of review process

    It may take several months to finalise the review outcome.

    It may take longer if all relevant information is not provided with the application.

    When finished, the review panel will issue a certificate containing written reasons for their decision within 20 working days of their last meeting.

    This will be sent to you and the other party.

    The decision is final and binding as to your eligibility for participation in the Scheme.

  • Paying for the review panel assessment

    The cost of the review panel assessment (including any necessary travel and accommodation) is paid for by icare lifetime care.

    If you choose to have a lawyer represent you, we can’t pay for your legal costs.

    For more information, contact us.

    Disputes about 'motor accident injury'

  • What disputing your 'motor accident injury' means

    To be accepted as a participant in the Scheme, your injury must meet the legal definition of ‘motor accident injury’.

    That is, both the motor accident and the motor vehicle involved must meet the definition in section 3B of the Motor Accidents Compensation Act 1999.

    A dispute occurs when you (or another party) disagrees with our decision about whether your injury is a ‘motor accident injury’.

    This is a legal dispute, which means it must be decided by a panel of legal professionals. 

  • Who can lodge a 'motor accident injury' dispute

    This type of dispute can only be referred by an ‘interested person’ who is affected by our decision.

    An interested person could be:

    • You (the injured person)
    • The insurer of a CTP claim
    • The Nominal Defendant (if your claim is allocated to an insurer as the vehicle at fault isn’t registered or can’t be identified, and the accident happened in NSW)
  • How to lodge your 'motor accident injury' dispute

    A dispute can only be lodged after you’ve received a written decision about your eligibility for the Scheme. The written decision needs to outline that you are not eligible for the Scheme because the motor accident or motor vehicle does not meet the legal definition.

    Your dispute needs to be made in writing within six months of receiving the decision.

    To find out more, contact us.

    We also have a support and advocacy service that can assist you to navigate our dispute process. See our advocacy page for more information on accessing this service.

  • Who assesses your dispute

    The dispute will be referred to the Principal Claims Assessor at the State Insurance Regulatory Authority.

    The Principal Claims Assessor will then convene a panel of three claims assessors to determine the dispute.

    Claims assessors are experienced legal professionals (solicitors or barristers) with expertise in assessing legal disputes. 

  • How the panel will make their decision

    The panel will make a decision on whether the injury is a ‘motor accident injury’. Their decision is final and is legally binding.

    This will affect whether you are eligible to participate in the Scheme on the basis of your motor accident. This is different from whether your injuries meet the criteria for participation.

  • Providing information to the panel

    Anyone involved in the dispute may want to talk to or forward information to the panel to be considered when making their decision.

    If this happens, we’ll make any arrangements needed to allow this to happen. It’s important that the panel has access to all information relevant to the accident so they can make an informed decision.

  • Length of dispute process

    This may take several months to finalise, and may take longer if all relevant information is not provided with the application.

    In some cases, the panel may need more information about the accident, either in writing or by talking to people involved. If this happens, you’ll be told what information is needed. 

  • What happens next

    The panel will certify their decision in writing and will include reasons for the decision. The panel’s assessment will also determine whether icare lifetime care must pay the injured person’s reasonable costs for the legal services they received relating to the dispute.

    This decision is legally binding and there is no provision in the legislation to appeal.

    For more information, contact us.