How Claims Assessors Evaluate Liability in NSW CTP 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).
In New South Wales, claims assessors play a key role in determining whether a motor accident claim is valid under the Compulsory Third Party (CTP) scheme. Insurers use these independent assessors to evaluate fault, injury severity, and eligibility for benefits. This process helps both claimants and insurers understand whether a claim meets the legal and medical criteria set by the Motor Accident Injuries Act 2017 and the NSW government’s SIRA guidelines.
The Role of a Claims Assessor
A claims assessor is an independent professional employed by an insurer to review claims. Their responsibilities include:
- Assessing whether the accident meets the legal definition of a 'motor accident' under NSW law.
- Evaluating whether the injury qualifies as a 'threshold injury' or higher under the Motor Accident Guidelines.
- Determining the level of fault attributed to each party, including whether a claimant contributed to the accident.
- Calculating the appropriate benefits, such as weekly income payments or treatment and care benefits.
Assessors rely on medical evidence, accident reports, and legal frameworks to make these decisions. Their findings are used to determine whether a claimant is eligible for benefits under the CTP scheme.
How Insurers Use SIRA Guidelines to Assess Liability
The State Insurance Regulatory Authority (SIRA) provides the official framework for assessing claims. Key factors insurers consider include:
- Threshold injury criteria: Under the Motor Accident Guidelines, injuries must meet specific clinical and neurological thresholds to qualify for benefits. For example, a spinal nerve-root injury with neurological signs may meet the threshold, even if there is no radiculopathy.
- Fault and contributory fault: Insurers assess whether the claimant or another party contributed to the accident. If a claimant is found to have contributed, their entitlement to benefits may be reduced.
- 52-week limit: If a claimant’s only injuries are threshold injuries, weekly benefits and treatment benefits are generally limited to 52 weeks after the accident date.
- Evidence requirements: Insurers require medical records, accident reports, and witness statements to support a claim. A lack of evidence may result in the claim being denied.
Practical Steps and Evidence That Matters
To support a CTP claim, claimants should gather:
- Medical records confirming the injury and its link to the accident.
- Police reports or accident statements from the scene.
- Witness contact details and statements.
- Income records to support claims for weekly payments.
- Correspondence with the insurer showing the timeline of the claim.
Insurers may request additional information if the evidence is incomplete or unclear. Claimants should ensure all documentation is accurate and submitted promptly.
Time Limits and When to Seek Advice
CTP claims have strict time limits. For example, weekly benefits are generally limited to 52 weeks if the injury is a threshold injury. If a claimant’s injuries exceed the threshold, benefits may continue beyond this period. However, the date of the accident determines which version of the CTP scheme applies (pre-1 December 2017 or post-2017).
If a claimant disagrees with an assessor’s decision, they may need to seek legal advice. A solicitor can help challenge the assessment or negotiate a better outcome. It is important to act quickly, as delays may reduce the chances of a successful claim.
Next Steps
CTP claims depend on the date of the accident, the nature of the injury, and the evidence provided. To understand your options, complete the quick, no obligation enquiry form. Every claim depends on its own facts.