If an insurer denies your CTP claim in NSW, particularly where you're returning to daily activities, you need to understand your legal rights. Under the Motor Accident Injuries Act 2017, insurers must assess claims based on medical evidence and statutory guidelines. This article explains how to challenge a denial, what evidence matters, and how SIRA resolves disputes in rural areas like Armidale.
Legal Obligations of NSW CTP Insurers
NSW insurers must evaluate claims according to the Motor Accident Injuries Act 2017 and SIRA guidelines. When denying a claim related to returning to daily activities, insurers must provide a written explanation citing medical evidence or statutory thresholds. For example, if a claimant is denied weekly benefits after 52 weeks, the insurer must reference s 4.4 of the Act, which limits benefits for threshold injuries. Insurers cannot refuse claims solely based on a claimant’s perceived ability to resume activities without medical support.
SIRA Guidance on Daily Activity Capacity
SIRA’s Motor Accident Guidelines clarify that insurers must assess a claimant’s recovery capacity using medical reports, not assumptions. If a claimant in Armidale is denied benefits for not returning to work or household tasks, they should request a copy of the insurer’s medical opinion. SIRA’s ‘What you can claim’ page (https://www.sira.nsw.gov.au/claims/motor-accidents/what-you-can-claim) outlines that weekly benefits and treatment benefits depend on the severity of injuries, not the claimant’s ability to perform daily tasks. Insurers must also consider the 52-week statutory limit for benefits where only threshold injuries are present.
Evidence to Counter Claim Denials
To challenge a denial, gather: medical records showing your injury’s impact on daily activities, a diary of your attempts to resume activities, and witness statements. For instance, if you were denied benefits for not returning to work, provide evidence of medical restrictions preventing you from working. SIRA’s ‘Making a motor accident claim’ page (https://www.sira.nsw.gov.au/claims/motor-accidents/making-a-claim) advises submitting all evidence to the insurer within 52 weeks of the accident. If the insurer refuses to accept your evidence, you may need to escalate the matter to SIRA.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident, but insurers can accept claims beyond this period if they meet certain criteria. If an insurer denies a claim after this timeframe, you may need to apply for a review under the Motor Accident Injuries Act 2017. SIRA’s dispute resolution process allows claimants to request a review of the insurer’s decision, including medical assessments of capacity to return to daily activities.
When to Seek Legal Advice
If an insurer denies your claim without a clear medical basis, or if you’re unsure how to respond to a denial, seek legal advice. A solicitor can help you challenge the denial, request a review, or pursue compensation for additional injuries not covered by the CTP scheme. In rural areas like Armidale, claimants should ensure they understand their rights under NSW law and the specific requirements of the CTP scheme.
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