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).
When an insurer denies a Compulsory Third Party (CTP) claim in New South Wales, caregivers and families often face significant financial and emotional strain. Understanding the legal framework and practical steps to challenge a denial is critical. This article explains how insurers typically deny claims, the specific challenges caregivers face, and how to dispute a denial using NSW laws and SIRA guidelines.
How Insurers Deny CTP Claims in NSW
Insurers may deny claims by arguing the injury does not meet the 'threshold injury' definition under the Motor Accident Injuries Act 2017 (MAIA). For example, they might claim the injury is minor or does not involve neurological signs. They may also dispute the need for caregiver support, arguing the injury does not result in long-term care requirements.
Common denial reasons include:
- Injury not meeting soft-tissue injury criteria (e.g., no spinal nerve-root injury)
- Lack of evidence linking the injury to the accident
- Claims of contributory fault by the injured person
- Disputes over the necessity of caregiver support
Challenges for Caregivers and Families
Caregivers often face:
- Financial strain from lost income or out-of-pocket expenses
- Emotional stress from managing care while dealing with the injury
- Difficulty proving the necessity of their role in the claim
Insurers may challenge the link between the injury and caregiver needs, requiring detailed evidence of the injury's impact on the injured person's ability to care for themselves.
Evidence to Dispute a Denial
To challenge a denial, gather:
- Medical records confirming the injury meets threshold criteria
- Statements from healthcare professionals about the injury's impact
- Proof of caregiver involvement (e.g., care logs, witness statements)
- Accident reports and witness details
- Correspondence with the insurer showing delays or inconsistencies
SIRA guidelines emphasize that evidence must directly connect the injury to the claim. For example, if the injury results in a need for daily assistance, medical reports must explicitly state this.
Navigating the Dispute Process in Ballina
If an insurer denies a claim, you can:
- Request a review through SIRA's internal dispute process
- Submit additional evidence to support your case
- Seek legal advice if the insurer refuses to reconsider
In Ballina, the NSW Motor Accident Claims Unit (SIRA) handles disputes. You must act within 52 weeks of the accident if your claim involves only threshold injuries, as weekly benefits typically stop after this period.
When to Seek Legal Advice
Consult a solicitor if:
- The insurer refuses to acknowledge your claim
- You need help gathering evidence
- You face a time limit for submitting a claim
- You believe the insurer is acting unreasonably
Legal professionals can help challenge denials, especially if the injury involves whole-person impairment or long-term care needs.
Practical Example
Consider a scenario where a car accident leaves a family member with a soft-tissue injury. The insurer denies caregiver benefits, arguing the injury does not meet threshold criteria. The family must provide medical evidence showing neurological signs, such as reduced reflexes or sensory loss, to challenge this denial.
Next Steps
CTP claim denials can have lasting impacts on caregivers and families. Understanding your legal rights and gathering strong evidence are essential. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.