How NSW CTP Insurers Assess Attendant Care Claims
In New South Wales, Compulsory Third Party (CTP) insurers must assess claims for attendant care services based on the Motor Accident Injuries Act 2017 and SIRA guidelines. Attendant care refers to paid assistance with daily living tasks like dressing, eating, or mobility after a serious motor accident. Insurers evaluate whether the injury meets the 'threshold injury' criteria and whether the care needs are medically necessary.
Insurers typically consider medical evidence, including reports from treating doctors, to determine if the injury qualifies. For example, a spinal nerve-root injury producing neurological signs may fall under the soft-tissue threshold injury definition. However, radiculopathy requires specific clinical signs as outlined in the Motor Accident Guidelines.
Key Factors in Approving or Denying Claims
CTP insurers assess claims by:
- Reviewing medical records to confirm the injury's severity and impact on daily living
- Evaluating whether the care needs are 'reasonably necessary' under SIRA's guidelines
- Considering the claimant's ability to perform basic self-care tasks
- Checking if the injury meets the 52-week statutory benefit period for weekly income payments
Insurers may deny claims if the injury does not meet the threshold injury definition or if the care needs are deemed temporary. For instance, a claimant requiring 24/7 assistance might be denied if the injury is classified as a 'soft tissue' injury without long-term functional impairment.
Using SIRA Resources to Challenge Decisions
Claimants in Illawarra and South Coast can use SIRA's resources to challenge insurer decisions. The 'What you can claim' page on SIRA's website outlines the types of care services covered, including:
- Assistance with personal hygiene
- Mobility support
- Meal preparation
- Transportation to medical appointments
If an insurer denies a claim, claimants should:
- Request a detailed explanation of the decision
- Submit additional medical evidence supporting the care needs
- Lodge a formal dispute through SIRA's online portal
- Seek legal advice if the claimant believes the decision is unfair
SIRA provides templates and guidance for disputing decisions, ensuring claimants understand their rights under the CTP scheme. For example, a claimant denied for not meeting the 'threshold injury' criteria could challenge the assessment by providing evidence of long-term functional limitations.
Practical Steps for Claimants
To support an attendant care claim, claimants should:
- Document all medical treatments and specialist opinions
- Keep records of care provider invoices and service logs
- Preserve accident reports, witness statements, and police reports
- Communicate with the insurer in writing to confirm claim status
Time limits are critical. Most weekly income benefits expire after 52 weeks unless the injury meets the 'whole person impairment' threshold. Claimants must submit evidence of ongoing care needs before this period ends.
When to Seek Legal Advice
Claimants should consult a solicitor if:
- The insurer denies the claim without clear reasoning
- The claimant's injury meets the threshold injury criteria but is denied
- The claimant needs assistance with dispute resolution processes
Legal professionals can help claimants navigate SIRA's dispute protocols and ensure their rights under the CTP scheme are protected. In complex cases involving multiple injuries or long-term care needs, legal advice becomes essential.
Next Steps
CTP insurers in Illawarra and South Coast must base decisions on medical evidence and SIRA guidelines. Claimants should act promptly to submit evidence and challenge decisions if necessary. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.