Understanding How CTP Insurers Assess Care and Family Support Claims
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
If you're in Auburn NSW and have a care or family support claim after a motor accident, you need to understand how insurers evaluate these claims. The NSW Compulsory Third Party (CTP) scheme determines what care and support is covered, and insurers use specific guidelines to make decisions. This article explains the legal framework, evidence needed, and steps to challenge unfair decisions.
Key Factors Insurers Consider
NSW CTP insurers assess care and family support claims based on the Motor Accident Injuries Act 2017 and SIRA guidelines. Factors include:
- Medical evidence: Doctors must confirm the injury caused the care need. For example, a spinal nerve-root injury with neurological signs (not just radiculopathy) may qualify under the soft-tissue definition.
- Type of care required: This includes paid and unpaid care, such as assistance with daily living tasks, medical equipment, or home modifications. SIRA’s What You Can Claim page outlines eligible care types.
- Family support needs: Insurers evaluate whether a family member’s ability to work or manage daily tasks is significantly impacted. This requires evidence like employment records or witness statements.
- Duration of need: Weekly benefits and treatment payments are generally limited to 52 weeks if only threshold injuries are involved. After this period, insurers may stop payments unless the claimant has a whole-person impairment of 10% or more.
How SIRA Guidelines Apply to Family Support Claims
SIRA’s Making a Motor Accident Claim guide states that family support claims must demonstrate a direct link between the injury and the care need. For example, if a child’s injury requires 24/7 supervision, the insurer must assess whether this is medically necessary and not a reasonable adjustment.
A practical example: A mother with a soft-tissue injury may need to stop working to care for her child. Insurers will check medical records to confirm the injury’s impact and compare it to SIRA’s threshold injury criteria. If the injury meets the soft-tissue definition, care payments may continue beyond 52 weeks.
Steps to Challenge Unfair Decisions
If an insurer denies or limits your care claim, you can:
- Request a review: Submit new evidence, such as a revised medical report or additional witness statements. SIRA’s Claim Review process allows for this.
- Seek independent medical opinion: A specialist report can clarify whether the injury meets the required criteria. For instance, if the insurer disputes a spinal nerve-root injury, a neurologist’s assessment may be needed.
- Appeal through the NSW Civil and Administrative Tribunal (NCAT): If the insurer refuses to review, you can apply to NCAT. This requires a formal application and may involve a hearing.
Time Limits and Practical Steps
You must notify your insurer within 52 weeks of the accident if you’re claiming weekly benefits. However, claims for care and family support can extend beyond this period if the injury meets the whole-person impairment threshold. Always keep records of:
- Medical reports
- Care provider invoices
- Employment records
- Witness statements
When to Seek Legal Advice
Insurers may use strict interpretations of SIRA guidelines to limit payments. If you’re unsure whether your claim meets the criteria, or if your insurer has denied your request without explanation, consult a solicitor. Legal advice can help you understand your options under the Motor Accident Injuries Act 2017 and ensure your claim is properly reviewed.
Next Steps
CTP insurers in NSW have specific rules for assessing care and family support claims. Understanding these rules helps you prepare evidence and challenge decisions if needed. If you’re in Auburn and need assistance with a claim, complete the quick, no obligation enquiry form to request contact about your circumstances.