When an insurer denies a Compulsory Third Party (CTP) claim in New South Wales, caregivers and families may face financial and emotional strain. This article explains how to navigate denied claims, focusing on the Central Coast and the legal obligations of insurers under NSW law.
What Happens When an Insurer Denies a CTP Claim?
Under the Motor Accident Injuries Act 2017, insurers must pay benefits if a claim meets the legal criteria. If a claim is denied, the insurer must provide a written explanation. For caregivers, this denial can disrupt essential support for injured family members. SIRA guidelines outline that insurers must assess claims based on medical evidence, not fault or the claimant’s financial situation.
Practical Steps for Caregivers and Families
- Review the Denial Notice: Insurers must specify which benefits were denied and why. Common reasons include disputes over injury severity or incomplete documentation. For example, if a claimant’s injury is classified as a 'threshold injury' (a soft tissue injury meeting specific medical criteria), benefits may be limited after 52 weeks.
- Gather Medical Evidence: SIRA requires claims to include medical records confirming the injury. If a caregiver is managing treatment, ensure all records are submitted, including specialist reports and therapy notes.
- Document Care Responsibilities: Keep records of time spent caregiving, such as notes on daily tasks, medical appointments, or reduced income due to caregiving duties. This evidence may support claims for additional support or income loss.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident, though extensions may apply for complex cases. If an insurer denies a claim, the claimant has 28 days to request a review. If the review is unsatisfactory, the matter can be escalated to the NSW Civil and Administrative Tribunal (NCAT) for mediation or a formal hearing.
SIRA Resources for Caregivers
SIRA’s 'What you can claim' page outlines benefits available to caregivers, including weekly income payments and treatment and care benefits. Families should also contact SIRA directly to request a review of their claim, as the organisation oversees the CTP scheme in NSW.
When to Seek Legal Advice
Caregivers should consult a solicitor if the insurer’s denial lacks clear legal reasoning or if the claimant’s needs are not being met. Legal experts can help challenge incorrect classifications of injuries or disputes over benefit amounts.
Example Scenario
A Central Coast resident, injured in a car accident, relies on their partner to manage medical appointments and household tasks. The insurer denies weekly income benefits, citing the injury as a 'threshold injury.' The caregiver must submit updated medical evidence to challenge this classification and request a review.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.