Navigating Delayed Insurer Decisions 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).
If your insurer has not made a decision on your CTP claim within a reasonable time, you are not without recourse. Under the Motor Accident Injuries Act 2017 (MAIA), insurers must assess claims promptly and provide a written decision. Delays may occur due to incomplete information, complex injury patterns, or administrative backlogs, particularly in regional NSW where access to medical specialists may be limited. However, a delay does not mean your claim is abandoned. You have the right to request a progress update and to escalate the matter through formal channels if necessary.
Legal Timeframes and Insurer Obligations
Insurers are required under the MAIA to make a decision on a claim within a reasonable timeframe. While the Act does not prescribe a fixed number of days, SIRA guidelines state that a reasonable timeframe generally means within 30 to 60 days of receiving complete information. If your insurer fails to respond within this period, you may consider sending a formal letter requesting a decision. The insurer must then respond within 14 days of receiving the letter. Failure to respond may allow you to apply to the State Administrative Tribunal (SAT) for a determination on the claim.
Preparing for Medical Assessments During a Delay
Even if an insurer has not yet decided on your claim, you may still be required to attend a medical assessment. These assessments are conducted by independent medical practitioners to determine the nature and extent of your injuries, including whether you have a threshold injury under the MAIA. You should prepare for these assessments by:
- Gathering all medical records, including treatment notes, imaging reports, and referrals from your medical practitioner.
- Keeping a record of all symptoms, pain levels, and functional limitations since the accident.
- Noting any changes in your ability to work, drive, or perform daily tasks.
- Bringing a list of medications and any psychological symptoms you have experienced.
A medical assessment is not a decision on compensation. It is a factual review used to assess your injury status and determine eligibility for statutory benefits or damages.
What You Can Claim While Waiting
While waiting for a decision, you may still be entitled to certain benefits. If you have a qualifying injury, you may receive treatment and care benefits, weekly income payments, or a lump sum for permanent impairment. These benefits are not contingent on a final decision from the insurer, but they do require a formal assessment. You can request that your insurer initiate the assessment process even if a decision on the claim has not yet been made.
Escalating a Delayed Decision
If your insurer has not responded to your request for a decision, you may escalate the matter. You can contact SIRA directly to report a delay. SIRA may intervene to encourage the insurer to act. Alternatively, you may apply to the State Administrative Tribunal (SAT) for a determination on your claim. The SAT can review the insurer’s actions and order a decision to be made. This process does not require a lawyer, but it is advisable to seek independent advice before proceeding.
When to Seek Independent Advice
A delayed decision does not necessarily mean your claim is at risk. However, if you have not received any communication from your insurer for more than 90 days, or if you believe the delay is unreasonable, you should seek advice. Independent legal or claims assistance services can help you understand your rights, review the evidence, and determine whether to escalate the matter. In regional NSW, access to legal advice may be limited, but SIRA provides free information and guidance through its website and contact centre.
Hypothetical Example
A driver in Wagga Wagga was involved in a motor vehicle accident in June 2024. The insurer did not respond to the initial claim submission for 100 days. The driver had ongoing neck pain and reduced mobility, and had been referred to a specialist. After sending a formal letter requesting a decision, the insurer still did not respond. The driver contacted SIRA, who advised that the insurer had failed to meet reasonable timeframes. The driver then applied to the SAT, which ordered the insurer to make a decision within 21 days. The assessment was completed, and the driver was granted treatment and care benefits.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.