Understanding CTP Insurance Disputes in NSW
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 you have been injured in a motor accident in New South Wales and your claim for compensation under green slip CTP insurance has been denied, rejected or not fully met, you have formal options to resolve the dispute. These options are governed by the Motor Accident Injuries Act 2017 and administered by the State Insurance Regulatory Authority (SIRA). Disputes may arise over the amount of weekly income payments, treatment and care benefits, or eligibility for damages. The process is designed to ensure fair resolution without immediate legal action.
How SIRA Manages CTP Disputes
SIRA oversees the CTP scheme and provides a structured pathway for resolving disputes. If you disagree with a decision made by your insurer, such as a refusal to pay for medical treatment, a reduction in weekly payments, or a denial of a damages claim, you can request a review. The first step is to contact the insurer and ask for a formal internal review. Insurers must respond within 28 days of receiving a request for review.
If the insurer upholds its original decision after internal review, you may apply to SIRA to review the matter. SIRA will assess whether the insurer’s decision was correct under the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. SIRA may also refer disputes to mediation if appropriate.
Mediation and Formal Review Options
Mediation is a voluntary process offered by SIRA to help parties reach an agreement without going to court. It is available for disputes involving weekly payments, treatment and care benefits, or damages. Mediation is not compulsory, but it is often effective in resolving disagreements over the value of a claim or the need for further treatment.
If mediation does not resolve the dispute, or if you choose not to mediate, you may apply to the Personal Injury Commission (PIC) for a formal review. The PIC is an independent body that hears disputes about CTP claims. It can review decisions on eligibility for damages, the level of weekly payments, or the adequacy of treatment and care benefits.
For disputes involving a medical assessment, such as a disagreement over the level of whole person impairment (WPI) or the need for future care, SIRA provides a formal medical dispute pathway. This allows you to request an independent medical assessment (IMA) to resolve clinical disagreements. The IMA is conducted by a qualified medical practitioner approved by SIRA and is binding on both parties unless challenged in the PIC.
When to Consider Legal Action
Legal action is not the first step in resolving a CTP dispute. However, if your claim has been denied and you believe the decision is incorrect, you may need to pursue a claim in the NSW Supreme Court or District Court. This is typically only necessary if:
- The insurer has refused to pay for treatment that is medically necessary and supported by a treating medical practitioner.
- You believe you are entitled to damages but have been denied on the grounds of the threshold injury test, and you have evidence that your injury meets the criteria for a non-threshold injury.
- The insurer has failed to respond to a review request within the required timeframe, or has made a decision that contradicts the Motor Accident Injuries Act 2017.
Before initiating legal proceedings, you must have exhausted internal review and SIRA review processes. The PIC must have made a final decision, or you must have waited 12 months from the date of your initial claim if no review was requested.
Evidence That Matters in a Dispute
To support a dispute, you must gather and preserve evidence that demonstrates the nature of your injury, the impact on your life, and the insurer’s actions. Key evidence includes:
- Medical records from your treating practitioner, including reports, assessments, and prescriptions.
- A detailed diary of your symptoms, pain levels, and how the injury affects your daily activities.
- Photographs of the accident scene, vehicle damage, or injuries.
- Witness statements, if available.
- Correspondence with the insurer, including emails, letters, and call logs.
- Pay slips or tax returns showing loss of income.
A medical report that clearly links your injury to the motor accident and supports a claim for WPI or future care needs is particularly important. If the insurer disputes a medical assessment, you may request an IMA through SIRA.
Time Limits and Procedural Deadlines
Time limits apply to dispute resolution steps. You must apply for an internal review within 28 days of receiving a decision. If you apply to SIRA for a review, you must do so within 60 days of the insurer’s final response. For a claim to proceed to the PIC, you must have a final decision from SIRA or have waited 12 months from your claim date.
Failing to meet these deadlines may prevent you from pursuing a claim. It is essential to act promptly and keep a record of all communications.
A Realistic Example
Sarah was a passenger in a car that was struck from behind in a car park in Sydney. She sustained a neck injury and was diagnosed with a soft-tissue injury. Her insurer approved treatment and care benefits but refused to pay weekly income payments on the grounds that her injury was not severe enough to qualify for ongoing payments. After 12 weeks, her doctor confirmed she was still unable to return to work. Sarah requested an internal review, which was denied. She then applied to SIRA for a review and was referred to mediation. The mediator helped reach an agreement on weekly payments, but the insurer still refused to cover future physiotherapy. Sarah then applied to the PIC, which upheld her claim for future treatment after reviewing her medical evidence and the insurer’s refusal to fund necessary care.
Next Steps: Seek Advice
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.