How Insurers Deny CTP Claims in NSW
Insurers may deny or limit CTP claims by disputing the injury's severity, claiming it falls below the 'threshold injury' definition, or arguing the claimant isn't entitled to specific benefits. For caregivers, this can create financial and emotional strain. Under the Motor Accident Injuries Act 2017, injuries must meet specific criteria to qualify for benefits like weekly payments or treatment costs. If an insurer denies a claim, it must provide a clear reason based on SIRA guidelines.
Practical Steps for Caregivers and Families
When a claim is denied, caregivers should:
- Gather medical records confirming the injury's impact on daily life
- Document how caregiving duties have affected income or employment
- Preserve accident reports, witness statements, and photos
- Review SIRA's 'What you can claim' guidelines to identify eligible benefits
Caregivers often face additional challenges, such as proving the necessity of care or demonstrating how the injury has altered family dynamics. For example, a person with a soft tissue injury (like a whiplash) may still qualify for benefits if it causes ongoing pain or limits mobility, even if it doesn't meet the 'whole person impairment' threshold.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident for certain benefits. If an insurer denies a claim, the claimant has 6 months from the denial date to challenge the decision. Disputes can be resolved through SIRA's dispute resolution process or by seeking independent medical opinions. Families should act quickly, as delays can reduce the chances of recovering benefits.
Example: Caregiver Claim Denied for Threshold Injury
Consider a scenario where a caregiver's claim is denied because the injury is classified as a 'threshold injury' under SIRA guidelines. While the insurer may argue the injury isn't severe enough, the claimant can challenge this by providing evidence of ongoing treatment, medical advice, or how the injury has impacted their ability to work or care for dependents. SIRA's guidelines on soft tissue injuries clarify that neurological signs beyond radiculopathy may still qualify for benefits.
When to Seek Legal Advice
Families should consult a legal professional if:
- The insurer denies benefits without a clear legal basis
- The claimant is struggling to meet SIRA's evidentiary requirements
- The injury has long-term effects on the caregiver's quality of life
Legal experts can help navigate SIRA's complex guidelines and ensure caregivers receive the support they need. In Western Sydney, local legal services can provide tailored advice for claims involving family-related challenges.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.