What SIRA Looks For in CTP Claims Assessments
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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).
New South Wales' State Insurance Regulatory Authority (SIRA) sets the rules for assessing motor accident claims under the Compulsory Third Party (CTP) scheme. When disputes arise, SIRA's guidelines define what evidence and documentation are required to support a claim. For example, claimants must demonstrate that injuries meet the 'threshold injury' criteria outlined in the Motor Accident Guidelines. This includes showing a spinal nerve-root injury with neurological signs, even if radiculopathy is not present. Medical records must clearly link the injury to the accident and show how it impacts daily life.
Practical Evidence for PIC Disputes
Personal Injury Claimants (PICs) in Bathurst should prepare specific evidence to challenge insurer decisions. Key documents include:
- Detailed medical reports from registered medical practitioners
- Accident reports from police or witnesses
- Photographs of the accident scene and vehicle damage
- Income records to support claims for lost wages
- Correspondence with insurers showing delays or denied claims
SIRA emphasizes that claims must be supported by 'objective evidence' such as medical imaging or clinical assessments. Subjective statements about pain or inconvenience are not sufficient on their own.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident for most benefits. However, disputes about claim validity can extend beyond this period. If an insurer rejects a claim, PICs can request a review through SIRA's internal process. This involves:
- Submitting a written objection within 28 days of the decision
- Providing additional evidence to challenge the initial assessment
- Requesting a medical review by a SIRA-approved specialist
It's important to note that SIRA's internal review does not guarantee a changed decision. The authority has discretion to uphold or revise the original assessment based on new evidence.
When to Seek Legal Advice
Disputes often arise when claimants believe their injuries are not being fairly assessed. For example, a cyclist in Bathurst might dispute a claim that their soft-tissue injury does not meet threshold criteria. In such cases, legal advice can help identify gaps in the evidence or procedural errors. A solicitor can also assist with:
- Applying for a medical review under the Motor Accident Injuries Act 2017
- Challenging decisions that fail to consider all relevant evidence
- Navigating the 52-week statutory benefit limits
Real-World Example
Consider a scenario where a motorist in Bathurst claims compensation for a whiplash injury. The insurer denies the claim, arguing there's no objective evidence of a spinal nerve-root injury. The PIC could challenge this by submitting MRI scans showing disc herniation and a medical report confirming neurological signs. This demonstrates how specific evidence can support a claim under SIRA's guidelines.
Next Steps
CTP claims depend on the specific facts of each case. To request contact about your circumstances, complete the quick, no obligation enquiry form.