Insurers assess distracted driving claims under the NSW Compulsory Third Party (CTP) scheme by applying the Motor Accident Injuries Act 2017 (MAIA). The decision to grant benefits or limit compensation depends on fault, injury type, and the availability of evidence. This article explains how insurers determine outcomes, what legal standards apply, and what claimants can do if they believe a decision is incorrect.
What Insurers Consider When Assessing Claims
Insurers begin by determining whether the driver was at fault for the accident. A distracted driving incident, such as using a mobile phone while operating a vehicle, may constitute a breach of road rules. Under the MAIA, liability for a motor accident is established by fault, not by whether the driver was distracted. The insurer will review evidence including police reports, witness statements, and mobile phone records to assess whether the driver’s actions contributed to the crash.
The nature of the injury is a key factor in determining the type and duration of benefits. The MAIA defines a threshold injury as one that includes soft tissue injury, such as a sprain or strain, or a spinal nerve-root injury that produces neurological signs other than radiculopathy. If the injury is classified as a threshold injury, the claimant may be eligible for statutory benefits, including treatment and care, weekly income payments, and a lump sum for permanent impairment. However, these benefits are subject to limits under the MAIA.
How SIRA Guidelines Influence Decision-Making
SIRA’s Motor Accident Guidelines provide the framework for assessing injury severity. These guidelines set out the clinical signs that must be present for an injury to qualify as a threshold injury. For example, a spinal nerve-root injury must demonstrate objective neurological signs such as altered reflexes, muscle weakness, or sensory changes to be considered within the soft-tissue definition.
Insurers use these guidelines to determine whether an injury meets the statutory threshold. If the injury does not meet the threshold, the claimant may be eligible to pursue a common law damages claim. However, the MAIA limits compensation for claims based solely on threshold injuries. Where a person’s only injuries are threshold injuries, weekly income payments and treatment and care benefits generally cease after 52 weeks from the date of the accident.
Practical Steps for Claimants
If an insurer denies a claim or limits benefits, claimants should act promptly to preserve their rights. The first step is to obtain a full medical assessment from a qualified medical practitioner. This should include a detailed record of symptoms, diagnosis, and prognosis. Claimants should also preserve all evidence related to the accident, including photographs of the scene, vehicle damage, and any correspondence with the insurer.
A claimant who believes their injury has not been properly assessed may request a review of the insurer’s decision. SIRA provides a process for disputing a decision, including the option to submit additional medical evidence or obtain an independent medical assessment. The claimant must provide a written request to the insurer and keep a copy of all submissions.
When to Seek Independent Advice
Insurers have discretion in applying the MAIA and interpreting the Motor Accident Guidelines. However, decisions must be based on the law and available evidence. If a claimant believes their injury has been misclassified, or if benefits have been denied without sufficient reason, independent legal advice may be necessary.
A solicitor can review the claim, assess whether the insurer’s decision complies with the MAIA and SIRA guidelines, and assist in challenging a decision through formal dispute processes.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.