CARS 2R – Reply to an application for general assessment of damages

Transcript

1 CARS Form 2R Reply to an application for general assessment of damages Motor Accidents Compensation Act 1999 Under section 94 of the This form is approved by the Authority in accordance with clause 8.1.1 of the Claims Assessment Guidelines. Use this form for assessment of: If you have received acknowledgement from the Claims Assessment and Resolution Service (CARS) • of a CARS 2A application for general assessment of damages. Instructions on completing the application form: 1. You must lodge the reply form within 20 working days of the date CARS sent the acknowledgement of the CARS 2A application. Send it to: The applicant, with a copy of all the material in support of the reply that has not previously been a. supplied b. CARS, with all material in support of the reply If your reply is not received within that time, the Principal Claims Assessor (PCA) may conduct a review or determination in the absence of a reply (cl. 12.4). Note: You must lodge a separate reply form and supporting documentation for each application that CARS has acknowledged. How to lodge the application: For assistance please contact: In person/Mail: Document Exchange: DRS on 1800 34 77 88 SIRA Dispute Resolution Services SIRA Dispute Resolution Services Claims Assessment and Resolution Service Claims Assessment and Resolution Service Email [email protected] State Insurance Regulatory Authority State Insurance Regulatory Authority Visit www.sira.nsw.gov.au Level 19, 1 Oxford Street, DX 10 Sydney Darlinghurst NSW 2010 If you need an interpreter to help you read this form, please contact: Associated Translators & Linguists Level 5, 72 Pitt Street, Sydney NSW 2000 Telephone: (02) 9231 3288 Fax: (02) 9221 4763 www.atl.com.au Office hours: 8.30 am to 5.00 pm, Monday to Friday Email: [email protected] Website: Page 1 of 17

2 Section Reply 1: This reply is made by the: Claimant ’ s legal representative Other/Non-CTP Claimant Insurer Insurer’s legal representative Claimant name Matt er number 2: Section Details about the accident Date of accident Location of accident (DD/MM/YYYY) Details about the claim Section 2a: If you are the claimant, the date the claim form If you are the insurer, the date the claim form (DD/MM/YYYY) received by the insurer (DD/MM/YYYY) sent to the insurer If you are the claimant: Is this a fault based claim only? OR Is this a no-fault claim – a claim made under the blameless accident provisions (Part 1.2 Div 1 of the Act)? OR Do you make both a fault and no-fault claim in the alternative? 3: Claimant information (details of the person who made this claim) Section Is the information the applicant gave Yes (go to section 4) No (provide correct details) in section 3 correct? Title Surname/f amily name Given name Gender (DD/MM/YYYY) Date of birth M F Other Claimant contact details Street address (include unit/street/property/Lot number if applicable – must not be a PO Box) Suburb Sta te P ostcode Country (if outside Australia) Page 2 of 17

3 Postal address (if different to Street address) Sta ostcode P te Suburb Country (if outside Australia) Mobile number Preferred daytime contact number Email Claimant personal information Interpreter required? If yes, wha t language Ye s No Do you have a disability we should know about to help you during the application process? Specify the disability Claimant unavailable dates Contact authority (claimant to complete) The claimant hereby gives permission for CARS and the CTP Assist to contact the below named person who has been designated as an authorised contact person for this matter to discuss my claim if necessary. Authorised contact name Authorised contact number Rela tionship to claimant (eg family, friend, lawyer) Email Claimant’s legal representative details Does this claimant have a legal representative? (If yes, provide details below). Ye s No Claimant’s legal representative contact details Firm Postal address or DX address (NSW DX only) ostcode Suburb Sta te P Page 3 of 17

4 Claimant’s legal representative name Reference Business phone number Email Section 4: Insurer information Is the information the applicant gave Yes (go to section 5) No (provide correct details) in section 4 correct? Including NSW CTP insurers, interstate insurers, the Nominal Defendant, other corporations or individuals against whom a claim is made (select only one). Is the person/entity against whom the claim is made a NSW CTP insurer? OR Is the person/entity against whom the claim is made a non-NSW CTP insurer? OR Is the person/entity against whom the claim is made a corporation or an individual? Details of CTP insurer (or non-NSW CTP insurer) Name of insurer Insurer claim number Postal address or DX address (NSW DX only) Suburb Sta te P ostcode Is the insurer acting for the Nominal Defendant? Ye s No Details of claims officer Title Claims officer name Business phone number Email Insurer’s legal representative details Does this insurer have a legal representative? (If yes, provide details below). No Ye s Page 4 of 17

5 Insurer’s legal representative contact details Firm (NSW DX only) Postal address or DX address Suburb Sta te P ostcode Insurer’s legal representative name Business phone number Reference Email Details of corporation/individual (complete this section if the claim is not made against a CTP insurer. For example, a transport company, warehouse or employer.) Name (NSW DX only) Postal address or DX address Suburb Sta te P ostcode Country (if outside Australia) Business phone number Email Corporation/individual’s legal representative details Does this corporation/individual have a legal representative? (If yes, provide details below). Ye s No Corporation/individual’s legal representative contact details Firm Postal address or DX address (NSW DX only) ostcode Suburb Sta te P Page 5 of 17

6 Corporation/individual’s legal representative name Reference Business phone number Email Section 5: Time limit information Is the information the applicant gave in section 5A or 5B correct? omplete the relevant section below) c Yes (go to section 6) No ( For personal injury or compensation to relatives claims made before 1 October 2008, complete section 5A. For personal injury or compensation to relatives claims made on or after 1 October 2008, complete section 5B. 5a: Section Claims made before 1 October 2008 – How do you say the section 91 Time Limits are satisfied? (if you do not satisfy one of the s 91 criteria the application may be rejected or dismissed) section 91(1)(a) is satisfied The insurer made an offer in accordance with s 82 more than 2 months ago. (if marked ‘x’ in the box enter ‘date of offer’ below, then go to section 6) Date of offer (DD/MM/YYYY) OR section 91(1)(b) is satisfied The period within which the insurer was required to make an offer in accordance with s 82 has expired and the insurer has failed to do so. (if marked ‘x’ in the box, enter both dates at i) and ii) then go to section 6) s 82(1) says that an insurer is required to make a reasonable offer to the claimant (unless the insurer wholly denies liability for the claim) after the latest of the following: i) Within 1 month after the claimant’s injury has stabilised, as agreed by the parties or as determined by a medical assessor. Date claimant’s injuries stabilised (Date agreement reached or date of MAS determination) (DD/MM/YYYY) Within 2 months after the claimant has provided to the insurer all relevant particulars of the claim ii) (under to s 82(5)) Date claimant provided all relevant particulars of the claim (DD/MM/YYYY) OR section 91(2) is satisfied The claim can be referred to CARS at any time. (if marked ‘x’ in this box, mark the box below which corresponds to the ground you say applies, then go to section 6) section 91(2)(a) is satisfied It is a claim in respect of which liability is wholly denied by the insurer. (if box marked ‘x’, enter details (if necessary) below, then go to section 6) Page 6 of 17

7 section 91(2)(b) is satisfied It is a claim in respect of the death of a person. (if box marked ‘x’, enter details below, then go to section 6) section 91(2)(c) is satisfied It is a claim in respect of an injury which has not stabilised within 3 years after the motor accident. (if box marked ‘x’, enter details below, then go to section 6) Provide any additional details about compliance with the time limits of s 91: 5b: Claims made on or after 1 October 2008 – Section How do you say the section 91 Time Limits are satisfied? (if you do not satisfy one of the s 91 criteria the application may be rejected or dismissed) section 91(1) is satisfied Please provide the information below if known. 28 days or more after the parties made their s 89C written offers. (if you marked x in the box you MUST enter ALL of the dates below and then go to section 6). Date of settlement offer made in accordance with s 82 (DD/MM/YYYY) AND Date of settlement conference held in accordance with s 89A (DD/MM/YYYY) AND Date of claimant’s offer made under s 89C (DD/MM/YYYY) AND Date of insurer’s offer made under s 89C (DD/MM/YYYY) OR section 91(2)(a) is satisfied Division 1A does not apply to the claim. (mark in a box below which one of 5 grounds applies, then go to section 6). section 89E(a) applies Claim is exempt from assessment under s 92(1)(a). (if you marked ‘x’ in the box, you should be lodging a CARS Form 1A). section 89E(b) applies The period within which the insurer was required to make a s 82 offer of settlement has expired and the insurer has failed to do so. Under s 82(1) the insurer has a duty to make a reasonable offer of settlement to the claimant on the latest of the following two events: (if you marked ‘x’ in the box you MUST enter BOTH dates below and go to section 6). Page 7 of 17

8 i) Within 1 month after the claimant’s injury has sufficiently recovered to enable the claim to be quantified. Date claimant’s injury sufficiently recovered (DD/MM/YYYY) OR Within 2 months after the claimant has provided to the insurer all relevant particulars about ii) the claim as required by s 85A. Date claimant provided all relevant particulars about the claim (DD/MM/YYYY) section 89E(c) applies The insurer wholly denies liability in respect of the claim. section 89E(d) applies The claim is in respect of the death of a person. section 89E(e) applies The claim is in respect of an injury that is not sufficiently recovered within 3 years after the motor accident to enable the claim to be quantified. OR section 91(2)(b) is satisfied A provision of Division 1A allows the claim to be referred for assessment. (mark in the corresponding box below which one of 2 grounds applies, then go to section 6). section 89A(3) applies Claim is exempt from assessment under s 92(1)(a). (if you marked ‘x’ in the box, enter details below, then go to section 6). Details section 89C(4) applies One party failed to make a s 89C offer within 14 days of conference. (if you marked ‘x’ in the box, enter details below, then go to section 6). Details OR section 91(2)(c) is satisfied The claim is being referred for exemption under s 92(1)(a) or (b). Page 8 of 17

9 OR section 91(2)(d) is satisfied A medical assessor has declined to assess impairment under s 132(3). (if you marked ‘x’ in the box, enter details of MAS matter number, medical assessor’s name and certificate date below, then go to section 6). Details 6: Section Assessment details Is the information the applicant gave in section 6 correct? Yes (go to section 6) No (c omplete the relevant section below) 6a: Suitability for assessment Section Only complete this section if you submit that this claim is not suitable for assessment under s 92(1)(b) of the Act and cl. 14.16 of the Claims Assessment Guidelines. If you submit that the claim is suitable for assessment skip this section and proceed to section 6B. Note: It is the circumstances of the claim at the time of the assessment that are relevant. If the claim is found to be unsuitable for assessment it will be exempted so that court proceedings can be commenced. Do you submit that the claim is NOT suitable for assessment? Yes – please select one or more of the circumstances below. You MUST attach submissions or a statement about why you say the claim is not suitable for assessment at CARS. If you do not attach submissions or a statement to this form, this application may be rejected or dismissed. The claim is exempt under s 92 (1)(a) because the claim involves one or more of the circumstances set out in cl. 8.11 (cl. 14.16.1); The heads of damage claimed by the claimant and the extent of any agreement by the insurer as to the entitlement to those heads of damage (cl. 14.16.2); The claim involves complex legal issues (cl. 14.16.3); The claim involves complex factual issues (cl. 14.16.4); The claim involves complex issues of quantum or complex issues in the assessment of the amount of the claim including but not limited to major or catastrophic, spinal or brain injury claims (cl. 14.16.5); The claimant has been medically assessed and is entitled to non-economic loss pursuant to s 131 and the claim involves other issues of complexity (cl. 14.16.6); The claim involves issues of liability including issues of contributory negligence, fault and/or causation (cl. 14.16.7); The claimant or a witness, considered by the assessor to be a material witness, resides outside the jurisdiction (cl. 14.16.9); The claimant or insurer seeks to proceed against one or more non-CTP parties (cl. 14.16.10); and/or The insurer makes an allegation that a person has made a false or misleading statement in a material particular in relation to the injuries, loss or damage sustained by the claimant in the accident giving rise to the claim (cl. 14.16.11). Page 9 of 17

10 Section Readiness for assessment 6b: If the matter is not ready to be assessed the application may be accepted but the allocation of the matter may be deferred under Chapter 12 of the Claims Assessment Guidelines (cl. 12.6) or dismissed under Chapter 13 of the guidelines, including if it is not likely to be ready to be assessed in the next 12 months (cl. 13.1.2). A claim is ready for assessment when all outstanding MAS disputes are resolved and the parties are otherwise ready to have the claim heard and determined. Is this claim ready for assessment? Yes (go to section 6C). No (select a r eason from the options below and go to section 6C). a. The claim w as made before 1 October 2008 and the claimant’s injuries have not yet stabilised. (DD/MM/YYYY) When do you say the claim will be ready for assessment? OR b. The claim w as made on or after 1 October 2008 and the claimant’s injuries have not sufficiently recovered to allow the claim to be quantified. When do you say the claim will be ready for assessment? (DD/MM/YYYY) OR c. Other – You MUS T provide reasons why you say the claim is not ready for assessment. When do you say the claim will be ready for assessment? (DD/MM/YYYY) Details: Page 10 of 17

11 Section Preferred location of assessment (you may choose only one) 6c: In accordance with cl. 15.16 of the Claims Assessment Guidelines the location must be a place where CARS is able to conduct an assessment according to the list of locations in Schedule 1 of the guidelines. You may nominate an alternate location below however you should not assume that the assessment will take place at that location. Sydney Other within NSW (if a location outside of the Sydney metropolitan area) Other (Interstate) Other (International) Section 7: Details about liability Is the information the applicant gave in section 7 correct? omplete the relevant section below) No ( c Yes (go to section 8). Section 7a: ls there an issue about liability for the claim? No – the insurer has wholly admitted liability for the claim (go to section 8). Yes – the insurer has either admitted liability for only part of the claim (go to section 7B) or has wholly denied liability for the claim (go to section 7C). Section 7b: If liability is admitted for only part of the claim The insurer has alleged contributory negligence on the part of the claimant (or the deceased in a compensation to relatives or pure mental harm claim). Provide details of the degree of contributory negligence alleged and the reasons given for the allegation. The insurer has alleged that some, but not all of the claimant’s injuries were caused by the accident. Provide details of which injuries the insurer does not admit are caused by the accident. Page 11 of 17

12 Other. Provide details of any other reason why the insurer has admitted liability for part of the claim. 7c: If liability is wholly denied for the claim Section The insurer has denied liability because: The insurer says its insured did not owe a duty of care to the claimant. The insur er says its insured did not breach the duty of care owed to the claimant. The insurer says that the claimant did not sustain any injury as a result of its insured’s breach of duty of care. The insurer rejects the claim for a procedural issue eg – the claim was made late. The insurer denies the claimant can recover under the blameless accident provisions of Part 1.2 of the Motor Accidents Compensation Act . The insurer denies the claimant can maintain a claim under the pure mental harm provisions of Part 3 the Civil Liability Act 2002 . The insurer, as agent for the Nominal Defendant, says the vehicle that caused the accident was uninsured and that the accident did not occur on a road or road related area. The insurer, as agent for the Nominal Defendant, says that the vehicle that caused the accident was unidentified and that due inquiry and search has not been made by the claimant to establish the identity of the unidentified vehicle. Provide details of the reasons given by the insurer for denying liability. Other. Page 12 of 17

13 Section Dispute information (what is in dispute?) 8: Entitlement to non-economic loss (a) [Non-economic loss or general damages is the amount of money assessed for the pain and suffering, loss of amenities and expectation of life and disfigurement experienced by the claimant as a result of the injuries sustained in the accident.] An application for general assessment cannot be lodged unless cl. 9.3 of the Claims Assessment Guidelines is satisfied. (If one of the cl. 9.3 criteria are not met, this application may be dismissed.) Is the information the applicant gave in section 8(a) correct? Yes (go to section 8(b)) No (cl. 9 .3 is satisfied, but not for the reasons provided by the applicant. Please provide details below.) No (cl. 9.3 is not satisfied. Please provide details below.) Details: Amount of non-economic loss (b) Is there a dispute in this claim about the amount of non-economic loss? Ye s No (c) Past economic loss or past loss of earning capacity [Past economic loss or past loss of earning capacity is a loss of earnings (wages or other income not able to be earned since the accident) or a loss due to deprivation or impairment of earning capacity or ability to earn wages or other income since the date of accident to the date of the assessment.] Is there a dispute in this claim about: Entitlement to past economic loss or Amount of past economic loss or N /A pas t los past loss of earning capacity s of earning capacity (d) Future economic loss or future loss of earning capacity [Future economic loss or future loss of earning capacity is the expected loss of future earnings (wages or other income not able to be earned after this assessment is finished) or the expected loss due to the deprivation or impairment of earning capacity or ability to earn wages or other income after the date of the assessment.] Is there a dispute in this claim about: Entitlement to future economic loss of future economic loss Amount N /A e los or futur s of earning capacity or future loss of earning capacity Page 13 of 17

14 Past treatment expenses (e) [Past treatment expenses are expenses incurred after the accident and before the date of the assessment. Past treatment expenses may include hospital, medical, dental, therapeutic, pharmaceutical, rehabilitation and respite care expenses.] Is there a dispute in this claim about: Entitlement Amount to past treatment of past treatment N /A expenses expenses [Future treatment expenses are expenses likely to be incurred after the assessment Future treatment expenses (f) finished. Future treatment expenses may include hospital, medical, dental, therapeutic, pharmaceutical, rehabilitation and is respite care expenses.] Is there a dispute in this claim about: Entitlement Amount to future treatment of future treatment N /A expenses expenses Past paid care (g) [Past paid care is compensation for care expenses incurred after the accident and before the date of the assessment. Past paid care is commercially provided services which assist the claimant with everyday tasks and includes (for example) personal assistance, nursing, home maintenance and domestic services.] Is there a dispute in this claim about: of futur Amount e treatment to past paid care Entitlement N /A expenses (h) [Future paid care is compensation for care expenses incurred after the assessment is finished. Future Future paid care paid care is commercially provided services which assist the claimant with everyday tasks and includes (for example) personal assistance, nursing, home maintenance and domestic services.] Is there a dispute in this claim about: e paid care N /A of futur to future paid care Entitlement Amount (i) Past gratuitous care [Past gratuitous care is compensation for services provided to the claimant after the accident and before the date of the assessment. Past gratuitous care is a service provided by another person who has not been paid and is not liable to be paid and the service must assist the claimant with everyday tasks and includes (for example) personal assistance, nursing, home maintenance and domestic services.] Is there a dispute in this claim about: N /A t gratuitous care Amount to past gratuitous care Entitlement of pas (j) Future gratuitous care [Future gratuitous care is compensation for services likely to be provided to the claimant after the assessment is finished. Future gratuitous care is a service provided by another person who has not been paid and is not liable to be paid and the service must assist the claimant with everyday tasks and includes (for example) personal assistance, nursing, home maintenance and domestic services.] Is there a dispute in this claim about: N /A e gratuitous care to future gratuitous care Amount of futur Entitlement Page 14 of 17

15 Section Document information (documents that must be attached in support of the reply 9: not attach originals)) (do All physical copies of documents and other material (including CD, DVD, electronic file, film or photographs) you submit in support of your application MUST be provided to each other party to the dispute. The reply may be rejected if the following are not listed below and attached: Claimant , If you are, or you act for the claimant and you are of the view the claim is suitable for assessment you must provide: a schedule of damages; • submissions setting out the basis of assessment for each head of damage claimed and if applicable, • the claimant’s s 85A statement; a signed statement from the claimant detailing matters that are relevant to the assessment; • signed statements from witnesses regarding the amount of damages to be assessed; and • if liability is in issue (the insurer has either denied liability or has admitted liability for only part of the • claim) a copy of the insurer’s s 81 notice, any correspondence concerning liability, the police report any witness statements or and any expert reports relevant to the issue of liability. • not suitable for assessment , If you are, or you act for the claimant and you are of the view the claim is you must provide: submissions explaining why the claim is not suitable for assessment plus all documentation you wish • to rely on to demonstrate why this claim is not suitable for assessment. If you are, or you act on behalf of the claimant and you are of the view the claim is not ready for assessment as the injuries have not stabilised or are not sufficiently recovered to enable the claim to be quantified, you must provide: medical evidence in support (less than 3 months old). • Insurer suitable for assessment , If you are, or you act for the insurer and you are of the view the claim is you must provide: a copy of the claim form; • a schedule of damages; • submissions setting out the basis of the insurer’s assessment for each head of damages claimed; • a statement of medical, rehabilitation or other expenses paid by the insurer to or on behalf of • the claimant; signed statements from witnesses regarding the amount of damages to be assessed; • if liability is in issue (the insurer has either denied liability or has admitted liability for only part of the • claim) a copy of the insurer’s section 81 notice, any correspondence concerning liability the police report any witness statements or and any expert reports relevant to the issue of liability. not suitable for assessment , If you are, or you act for the insurer and you are of the view the claim is you must provide: submissions explaining why the claim is not suitable for assessment plus all documentation you wish • to rely on to demonstrate why this claim is not suitable for assessment; a copy of the claim form. • If you are, or you act on behalf of the insurer and you are of the view the claim is not ready for assessment as the injuries have not stabilised or are not sufficiently recovered to enable the claim to be quantified, you must provide: medical evidence in support (less than 3 months old); • a copy of the claim form. • Page 15 of 17

16 You must number the first page of the top right hand corner of each document in accordance with the list over the page. In the case of surveillance images, any investigator’s or loss adjuster’s report concerning the surveillance images must be sent to the other party and lodged at CARS. The surveillance images or footage must be provided in an unedited digital format, with details also provided advising which specific portions of the images or footage are relevant to the issues in dispute. The claimant will be offered the opportunity to respond to the surveillance images and unless the claimant indicates otherwise, the claimant will be taken to have no objection to the assessor considering the surveillance images (cl. 17.7). All documents attached to this reply must be listed in section 9 of this form. You must clearly number the first page of each document at the top right hand corner, in accordance with that list. Please refer to cl. 17.14 of the Claims Assessment Guidelines for lodgement of late additional documents or information. Document Name of document (eg report Dr J Smith) Date (eg 29/07/2018) number R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 R16 R17 R18 R19 R20 R21 R22 You must send to CARS a copy of this reply and all supporting documentation. You must send to the respondent a copy of this application and all supporting documentation that has not previously been supplied to the respondent. If the reply is accepted, a copy of all documentation provided by the parties will be provided to the assessor who will assess the claim. If you need more space, you should use the ‘extra documents information’ page, continue the numbering from this page and attach it to your reply. Page 16 of 17

17 Important facts about privacy In handling personal and health information, the Authority is subject to the NSW Privacy and Personal and the NSW Health Records and Information Privacy Act 2002 Information Protection Act 1998 . The information we ask you to provide is required to enable the Authority to carry out its functions under Motor Accidents Compensation Act 1999 the , in accordance with the Claims Assessment Guidelines. If relevant information is not provided, the Authority may be unable to process your application. The information collected by the Authority is for the purpose of dealing with your application. It will be used for this purpose and for any subsequent consideration of matters relevant to the claim. It may also be used for associated administrative purposes including the monitoring and review of the Motor Accidents Scheme. Authority staff involved in these functions, any assessor(s) assigned to consider your application and their support staff will have access to the information. You have rights to access personal and health information about you held by the Authority and to correct this information in certain circumstances. Further details about how to exercise these rights is available from the SIRA Privacy Officer on 1300 656 919. The information will be held and stored by the State Insurance Regulatory Authority, Level 19, 1 Oxford Street, Darlinghurst NSW 2010. 10: Signature section Section The signature of person completing this form: s Insurer’s Claimant ’ Other Insurer Claimant legal representative legal representative If other, relationship to claimant Surname/family name Given name Signature Dat e reply form completed (DD/MM/YYYY) Reason why claimant did not sign (if not legally represented) (DD/MM/YYYY) Date reply form sent to CARS (DD/MM/YYYY) Date reply form sent to the respondent Catalogue No. SIRA08845 Dispute Resolution Services, State Insurance Regulatory Authority Level 19, 1 Oxford Street, Darlinghurst, NSW 2010 | The Concierge 1800 347 788 Website www.sira.nsw.gov.au © Copyright State Insurance Regulatory Authority 0918 Page 17 of 17

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