Complaints about insurers

This policy explains how we handle complaints about insurers that are within the responsibilities of the IRO. You may also download a PDF copy of this policy.

Introduction

The Independent Review Officer is an independent statutory officeholder established under Schedule 5 of the Personal Injury Commission Act 2020 (PIC Act). The Independent Review Office (IRO) is a government agency that supports the Officer in carrying out their work.

The role of the Independent Review Officer is set out in the law (Schedule 5, clause 6 of the PIC Act). Their job includes handling complaints from people who were injured at work or in a motor vehicle crash when they are unhappy with something their insurer did or did not do. The role also includes encouraging insurers and employers to have proper complaint handling processes for issues that come up under the relevant laws that govern the NSW workers' compensation and compulsory third party (CTP) insurance schemes.

The objects of the PIC Act say that where decisions are made, they should be timely, fair, consistent and of a high quality.^[1] The IRO must follow these decision-making principles when handling complaints about insurers.

If a complaint is about the actions of insurers, an insurer's case manager, or self-insurers, the IRO may ask for more information so that we can use it to inform our work.

The IRO cannot change the decision on your claim, but we will explain what we can and cannot help you with. If your complaint is outside of our role or legal authority, we will let you know as soon as possible and direct you to another agency that might be able to help.

We follow a 'no wrong door' approach, which means we try to make it easier for people to get the support they need to resolve their issues. We will help you get to the most appropriate agency to support you, if it is not us.

This policy explains how we handle complaints about insurers that are within the responsibilities of the IRO.

How to make a complaint

If you have an issue with your insurer you are encouraged to first raise that issue with them. You should explain your concerns to them and give them the opportunity to resolve the issue. You can do this by making a complaint to them, or asking for a review of a decision. If you are not sure how to make a complaint to your insurer, or to ask for a review of a decision they have made, you should ask your claims managers.

If you are not satisfied with how your insurer has handled your complaint, or reviewed a decision and you think they are being unfair, then you can complain to the IRO.

Making a complaint to us is simple. You can make a complaint to us any time using our online form. If you need help using our website, you can also call us on 13 94 76.

What we need from you

When making a complaint, please provide:

• the name of the insurer your complaint is about,
• details of your complaint, including what is the problem, when and how it started, how it has affected you and what your insurer has done so far,
• what outcome you are hoping for by making your complaint to the IRO,
• information to identify you, for example, your claim number,
• how you would like us to handle your complaint.

Your responsibilities

When you work with us, we ask that you:

• treat our staff with courtesy and respect,
• give us the information we ask for so we can help with your complaint,
• cooperate with us during the process,
• read or listen carefully to the information we provide,
• let us know how you would like us to communicate with you,
• tell us if anything changes that could affect how we handle your complaint after you have made it.

We want to hear your complaint in your own words

We want to hear about your experience with the problems you have had with the insurer, explained in your own words. We know that some people use artificial intelligence (AI) to help find information or write their complaints. While AI can be helpful, it can sometimes get the law wrong, misunderstand information or raise issues that our office is not able to deal with.

If you copy us into an email (using 'cc' or 'bcc') or send the same email to multiple people, we will treat that message as being 'for information only'. This means we will not take action based on that type of communication.

What we will do

We understand that the personal injury compensation system can be confusing and hard to navigate. We use a 'tell us once' approach because we understand that going through a traumatic event can be upsetting, and having to repeat your story can be difficult. By taking a 'tell us once' approach, we focus on your wellbeing and safety. We will listen carefully and try to understand your point of view.

We will:

• focus on your individual needs and circumstances,
• treat you with dignity, compassion and respect,
• handle your complaint in a respectful and responsive manner.

We will keep in contact with you regularly, responding in a timely way, making reasonable adjustments where needed, and handling complaints fairly and objectively.

Complaints we can help you with

You can contact us if you have a complaint about an insurer that affects your rights, entitlements, or obligations under NSW workers' compensation legislation or the CTP scheme.

Examples of complaints we can help with include:

• delay by the insurer in paying weekly benefits, reimbursements, or benefit awards decided by the Personal Injury Commission,
• delays in the insurer deciding liability or responding to requests for care or treatment,
• the insurer not providing documents about your claim that you have asked for,
• concerns about how your claim is being managed including how the insurer has handled complaints you have made to them, or how they have handled an internal review of their decisions about your claim,
• concerns about how the insurer arranges or schedules independent medical or other examinations and assessments.

You should contact us if:

• your insurer has not fixed the problem you have within the required time,
• you are not satisfied with the insurer's response to your issues,
• you believe the information the insurer has given you is incorrect,
• you consider the decision made by the insurer to be unfair or incorrect based on your circumstances and your understanding of your rights and entitlements.

Our model for managing complaints has 3 levels

We adopt a tiered service delivery model for complaints about insurers. Once we receive your complaint, we will progress it through the appropriate pathway. This means that the right person, at the right time, will assist with your complaint about the insurer.

As an incidental consequence of dealing with complaints, we also receive enquiries. If you make an enquiry, we will deal with it by responding to your query without the need to alert any insurer or other agency.

Our commitment to you

We will:

• acknowledge your complaint within two (2) working days of receiving it,
• review your complaint and contact your insurer,
• keep you updated regularly on how your complaint is progressing,
• review the facts and circumstances of your complaint to make sure we gather all the relevant information,
• provide clear and meaningful responses that explain the reasons for any actions or decisions we make,
• work with your insurer to resolve issues or clear up misunderstandings about how the laws and regulations apply to your claim,
• aim to resolve your complaint within 30 calendar days which is the legislative timeframe. If we need more time, we will contact you and keep you informed throughout the process.

Deciding not to handle a complaint

In some cases, we may decide not to deal with a complaint if we consider it to be frivolous, vexatious or for another valid reason decided by the Independent Review Officer.^[2] Each case is assessed individually and we will explain our reasons if we make this decision.

Our model for managing complaints

We will decide the best approach to handling your complaint. Most complaints are handled the first time you contact us.  At level 1, we may:

• explain how you can work with your insurer to fix the problem if you have not already tried,
• give you information,
• refer you to another organisation if they are better placed to help.

Front line staff will be appropriately trained to respond to such complaints, including being given appropriate authority, support and supervision.

Your complaint may be handled at level 2 if you have already tried to resolve the issue with the insurer and it was not successful. More senior staff will review and progress the unresolved complaints from level 1, or directly progress complex or serious complaints. Level 2 complaints involve a more complex problem, multiple problems or situations where we may need to look into the matter in more detail. At level 2, we may try to reach a reasonable solution or conduct more detailed enquiries.

At level 2, we will:

• speak with you and your insurer separately about the issue,
• ask you or your insurer for more information if needed,
• assess whether the insurer's response is correct and fair under the relevant legislation and guidelines,
• let you know the outcome of our assessment.

We may issue a formal notice to the insurer asking for more information or to explain what they have done to try and resolve your complaint. This can happen if your complaint has several issues or you have raised concerns about your claim over a long period of time.

We will tell you the outcome of your complaint and explain any next steps. We will always explain our reasons clearly and openly.

If a matter progresses to level 3, we will advise you about existing external review and appeal avenues. If we are going to refer your complaint, we will ask for your consent before doing so.

No Further Action decisions

If we are unable to resolve your complaint with your insurer, and there is no new information or further action we can take to help you, we may close the complaint with a decision of 'no further action' (NFA).

When we make a NFA decision, we will explain the reasons for it. This may include that we have no further powers to resolve your complaint, or your complaint needs to be handled by another agency. We will explain the options that are available to you if we decide to take NFA.

For workers compensation matters, this may include referring you to our Independent Legal Assistance and Review Service (ILARS) giving you access to independent legal advice and representation to look at the decisions of your insurer under the claim and, if appropriate, lodge a dispute with the Personal Injury Commission.

We will let both you and the insurer know when we make a NFA decision and explain our reasons. You can ask for an internal review of this decision if you do not agree with it.

What you can do if we have not met your expectations

Asking for internal review of our decision

Before asking for a review of our decision, you should contact the IRO officer who told you about the decision. This gives you a chance to talk through the reasons for the decision and ask any questions you still have. If you are still unhappy after this discussion, you can ask for an internal review. For more information, please refer to our guidance on 'How to ask for internal review of our decision'.

Complaints about us to the NSW Ombudsman

If you are unhappy with the internal review decision of the IRO or we have not met your expectations, you can make a complaint to the NSW Ombudsman.

Contact information for the NSW Ombudsman

Telephone: 1800 451 524 (Monday to Friday between 9am to 4pm)

Website: www.ombo.nsw.gov.au

Our role

Our role includes dealing with complaints from people who are injured at work or in a motor vehicle crash when they are unhappy with something their insurer did or did not do, including encouraging insurers and employers to have proper complaint handling processes.

Our role is set out in law^[3] and gives us authority to:

• require an insurer to give us specific information,
• investigate a complaint and report on it, including by making recommendations to an insurer (these recommendations are not legally binding), and
• decide not to deal with a complaint if there is a valid reason to do so.

We cannot require an insurer to change a decision. We do not review the decisions of insurers, or claims.

Regulatory intelligence can help improve how the personal injury system works

In addition to handling individual complaints, we use the information that we receive from complaints to understand the issues being experienced by people who are injured at work or on the roads.

We share information with the regulator to help improve the schemes. For example, we may let the State Insurance Regulatory Authority (SIRA) know when:

• we see what appears to be significant breaches of the law,
• where we believe that the conduct of an insurer appears to have caused significant harm to a person who is injured, or
• referring a matter may be in the public interest or could potentially impact a substantial number of claims.

When we receive complaints, we may also become aware of information that should be shared for other purposes. This can include information used to:

• support engagement with stakeholders,
• inform Parliamentary hearings,
• help develop regulatory insights,
• be considered as part of a formal Inquiry by the Independent Review Officer.

This helps us understand the wider issues and contribute to improvements in the schemes.

We work closely with other agencies and the NSW regulator

We work with other agencies that regulate or administer the workers compensation and CTP insurance schemes in NSW. These include:

• SIRA
• the Personal Injury Commission (PIC)
• Insurance and Care NSW (icare)

SIRA is the NSW regulator for the workers compensation and CTP insurance schemes. We support SIRA by providing information about individual cases where we believe there may be issues that SIRA should look into as part of its regulatory role. You can find more information about SIRA and what it does on its website: www.sira.nsw.gov.au

Privacy, record keeping and information handling

We collect and store records securely, in line with NSW State Records legislation on record keeping.

We handle all personal information in line with privacy laws, including the:

• Privacy and Personal Information Protection Act 1998 (NSW), and
• Health Records and Information Privacy Act 2022 (NSW).

When someone makes a complaint to us, the people who are injured (or their representatives) agree that we can share that information where needed to carry out our legal role. To support reporting and ongoing improvement, we may provide insurers with regular summary reports when they ask for them.

These reports show:

• how many complaints we have received about the insurer, and
• the outcomes of those complaints.

Our IRO Privacy Statement gives a general overview of how we collect, use and manage information from people who make complaints.

Respectful treatment

We are independent of your insurer and here to assist you. We know that issues with a claim can be frustrating, and that workers compensation and CTP schemes are complex. Sometimes people who complain to us can express their frustration to our staff.

We do not tolerate abuse or threats towards our staff. We ask that you do not raise your voice, swear or threaten our staff.

Unreasonable conduct or behaviour

Unreasonable behaviour can affect our ability to do our work properly. If a person's behaviour negatively or unfairly affects the health and safety of our staff, or the fair use of our services, we will take firm and appropriate action to manage the situation. For example, if a staff member is treated disrespectfully in the course of a call, they may end that call.

Unreasonable conduct or behaviour includes difficult or challenging actions that go beyond what is acceptable. Examples of difficult or challenging behaviour include:

• a person engaging in unacceptable behaviour and unreasonable conduct such as extreme anger, aggression, threats or other threatening or violent conduct, including intimidating or bullying our staff. This may include derogatory, racist or grossly defamatory remarks, or acts that constitute a criminal offence.
• a person persisting with their issues even though they have been finalised and explained to them or refusing to accept a final decision that we have made. A person might engage in excessive phone calls or amounts of correspondence to us, after being asked not to do so, where they raise no new grounds or issues for us to consider.
• a person insisting on outcomes that are unattainable after we have explained our role and legislative authority, the steps we are taking and how long it will take. A person might continuously change their request to us, or demand to have their matters dealt with in a particular way.
• a person providing disorganised and excessive information to us, or information that is unrelated to any of the issues raised. A person may fail to provide relevant information because it does not suit or support their position or argument, refuse to define their issues of concern when they are capable of doing so and we have asked them, or they may be unwilling to consider other points of view about an issue.
• a person making arguments which are not reasonable, including arguments which lack a factual or logical basis and are not supported by evidence. A person may irrationally interpret facts or laws and refuse to accept other interpretations or points of view or reasonable contrary information.

A person who behaves unreasonably may show one or more of these types of behaviour.

When this happens, we usually manage it by changing or limiting the ways in which we interact with that person, or how we deliver services to them. We will make all attempts to continue to provide services.

Any limits we put in place will be adjusted to suit each person's situation. For example, we consider things like language needs, reading and writing ability and cultural background. This may include:

• limiting which staff members the person can contact
• limiting the issues they can raise with us
• limiting when, where and how they can contact us.

In very rare situations, we may stop a person from accessing our services altogether.

This Policy

This policy was developed using well-established complaint handling guidelines. These include:

• the NSW Ombudsman's Effective Complaint Management Guidelines (November 2024) (pdf)
• the Australian Standard Guidelines for complaint management in organizations (AS 10002:2022)

This policy is also informed by the NSW Ombudsman's report titled NSW public sector complaint handling in 2025, which was tabled in the NSW Parliament on 9 March 2026.

Footnotes

1. See section 3(d), Objects of Act.
2. Schedule 5, Part 4, clause 8(5) of the PIC Act.
3. Schedule 5, Part 4 of the PIC Act states that one of our functions is ‘to deal with complaints made to the Independent Review Officer’