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).
Domestic duties care costs are a key part of NSW CTP claims when injuries prevent someone from managing household tasks. Insurers assess these costs based on medical evidence, the nature of the injury, and whether the care is medically necessary. This article explains how insurers evaluate claims, what factors influence their decisions, and steps claimants can take to challenge or appeal a decision.
How NSW CTP Insurers Evaluate Domestic Duties Care Costs
Under the Motor Accident Injuries Act 2017, insurers must consider domestic duties support as part of a claim if the injury limits a person’s ability to perform everyday tasks. SIRA guidelines state that care costs are only payable if they are 'reasonably necessary' to maintain the injured person’s health or prevent complications. This means insurers will review medical reports to determine whether tasks like cooking, cleaning, or personal hygiene are required.
Insurers also assess the duration of the need for care. For threshold injuries (soft tissue injuries meeting specific medical criteria), benefits are generally limited to 52 weeks. If the injury is more severe, such as a whole person impairment, the insurer may cover longer-term support. The key is whether the care is directly related to the injury and not a lifestyle choice.
Factors Influencing Insurer Decisions
Insurers evaluate claims based on three main factors:
- Medical necessity: Are the domestic duties essential to prevent health deterioration? For example, a claimant with a spinal injury may need help with mobility tasks, but routine cleaning might not qualify.
- Evidence of need: Medical practitioners must document the necessity of care in reports. Without clear evidence, insurers may reject the claim.
- Reasonable cost: Insurers will only cover care that is 'reasonably necessary' and within standard industry rates. Excessive or unnecessary requests may be denied.
A hypothetical example: A claimant with a broken leg may need assistance with cooking and personal hygiene for six weeks. However, if the injury is a minor sprain, the insurer may limit support to 52 weeks, as per the Act.
Practical Steps for Claimants
If an insurer denies or limits domestic duties support, claimants can take the following steps:
- Request a detailed explanation: Insurers must provide reasons for their decision, including which SIRA guidelines or legal provisions apply.
- Seek a second medical opinion: A specialist report can clarify whether the care is medically necessary.
- Appeal through SIRA: Claimants can submit a formal objection to the insurer’s decision. If the dispute continues, the NSW Civil and Administrative Tribunal (NCAT) can review the case.
Time Limits and Dispute Options
Claimants must notify insurers of their intention to claim domestic duties support within 52 weeks of the accident. If the injury is a threshold injury, benefits are generally limited to 52 weeks. For more severe injuries, the time limit may be extended, but insurers will still assess the claim based on medical evidence.
If an insurer’s decision is unfair, claimants can request a review under the Motor Accident Injuries Act 2017. The process involves submitting a written objection and providing additional evidence to support the claim.
When to Seek Legal Advice
Domestic duties care costs can be complex, especially when insurers dispute the necessity of care or the amount of compensation. Legal advice is recommended if:
- The claimant’s injury is a whole person impairment.
- The insurer denies the claim without a clear explanation.
- The claimant needs to challenge a decision made by SIRA or NCAT.
Next Steps
CTP entitlements depend on the accident date, injury type, and claim history. To request contact about your circumstances, complete the quick, no obligation enquiry form.