How NSW CTP Insurers Evaluate Domestic Duties Care Claims
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).
If you're injured in a motor accident and need help with household tasks like cooking, cleaning or shopping, you may be eligible for domestic duties care costs under NSW CTP insurance. However, insurers in Armidale and across NSW assess these claims carefully based on strict guidelines. This article explains how insurers evaluate the necessity and cost of domestic duties care, what evidence you need to support your claim, and how to challenge a decision if you believe it's unfair.
The Legal Framework for Domestic Duties Claims
Under the Motor Accident Injuries Act 2017, NSW CTP insurers must cover reasonable domestic duties care costs when an injury limits a person's ability to perform daily tasks. The SIRA Guidelines (State Insurance Regulatory Authority) outline that care costs must be:
- Necessary to maintain a reasonable standard of living
- Reasonable in cost and duration
- Directly related to the injury's impact on daily functioning
Insurers assess whether the care is 'reasonably necessary' by considering medical evidence, the nature of the injury, and the claimant's ability to perform tasks independently. For example, a person with a broken leg may need help with cooking for 6 weeks, but a long-term spinal injury might require ongoing assistance.
Evidence Required to Support Your Claim
To prove your domestic duties care costs are covered, you'll need to provide:
- Medical documentation from a treating practitioner confirming your injury limits daily tasks
- Care provider records showing the type of assistance needed (e.g., cleaning, shopping, meal preparation)
- Expense records like receipts, invoices or bank statements for care costs
- Witness statements if available to confirm the need for assistance
Insurers often request these documents to verify that the care is directly related to the injury and not a lifestyle choice. For instance, if you're claiming help with gardening but have no medical evidence of mobility issues, the insurer may reject the claim.
How to Challenge an Unfair Decision
If your insurer rejects your domestic duties claim, you can dispute the decision by:
- Reviewing the rejection letter to understand the specific grounds for refusal
- Submitting additional evidence that wasn't previously provided
- Requesting a review through the insurer's internal appeals process
- Seeking independent assessment from a SIRA-approved medical expert
Insurers in Armidale must follow the Motor Accident Injuries Regulation 2017 when handling disputes. If you believe the decision is unjust, you may also contact the NSW Civil and Administrative Tribunal (NCAT) for further review.
Example: A Claimant's Experience
Consider a hypothetical case: Maria, a 45-year-old mother, was injured in a car accident and required help with daily tasks for 12 weeks. She submitted receipts for 12 weeks of cleaning and cooking assistance, along with a doctor's note confirming her injury limited her ability to perform these tasks. The insurer initially rejected the claim, arguing the care was 'not reasonably necessary.' Maria challenged the decision by providing additional evidence, including a detailed care plan and a second medical opinion. The insurer eventually approved the claim after reviewing the updated documentation.
Time Limits and Next Steps
You have 52 weeks from the accident date to claim certain benefits under the Motor Accident Injuries Act 2017. After this period, insurers may limit or stop payments for care costs unless the claimant has a long-term impairment. If your claim is rejected, act quickly, insurers typically have 60 days to respond to a dispute request. If you're unsure how to proceed, contact a legal professional for guidance.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.