If your CTP claim was denied because you're returning to daily activities, you're not alone. NSW insurers often deny claims by arguing that claimants have recovered, but proving your inability to resume normal activities requires specific evidence. This article explains how insurers assess daily activity claims under the Motor Accident Injuries Act 2017, what evidence matters, and how to challenge a denial.
How NSW CTP Insurers Evaluate Daily Activity Claims
NSW insurers deny claims by asserting that claimants have returned to their pre-accident level of function. Under the Motor Accident Injuries Act 2017, benefits are limited to injuries that meet the 'threshold injury' definition in the Motor Accident Guidelines. If your injuries fall below this threshold, insurers may argue you've recovered.
To challenge a denial, you must prove that your injuries prevent you from resuming daily activities. This requires medical evidence showing:
- Clinical signs of ongoing impairment (e.g., pain, mobility issues)
- Functional limitations affecting daily tasks (e.g., cooking, shopping)
- A direct link between your injuries and your inability to perform these activities
Insurers often request activity logs, medical reports, and expert opinions to assess whether you've met the threshold injury criteria. Failure to document these elements can lead to claim denials.
Key Evidence for Daily Activity Claims
When disputing a denial, focus on three types of evidence:
1. Medical Documentation
Your treating medical practitioner must confirm that your injuries prevent you from resuming daily activities. This includes:
- Detailed injury reports
- Functional capacity assessments
- Notes on how your injuries affect daily tasks
2. Activity Logs
Keep a daily record of activities you're unable to perform. For example:
- 'Unable to lift groceries due to back pain'
- 'Struggles to walk 500 meters without resting'
3. Expert Opinions
Independent medical experts may be required to assess whether your injuries meet the threshold injury definition. This is particularly important if your claim involves soft tissue injuries or spinal nerve-root issues.
SIRA's Role in Disputing Denials
The State Insurance Regulatory Authority (SIRA) oversees CTP claims and provides guidelines for assessing daily activity limitations. When insurers deny claims, SIRA evaluates whether the claimant's injuries meet the threshold injury criteria. If your claim involves soft tissue injuries, be aware that:
- Spinal nerve-root injuries with neurological signs may qualify as threshold injuries
- Radiculopathy requires specific clinical signs under the Motor Accident Guidelines
SIRA also determines whether your injuries fall below the threshold, which can affect your eligibility for benefits. If your claim is denied, you may need to request a review of the assessment.
Common Mistakes to Avoid
Many claimants fail to challenge denials effectively by:
- Not documenting daily activity limitations
- Relying on informal evidence (e.g., social media posts)
- Failing to follow up with the insurer after a denial
To avoid these pitfalls, ensure you:
- Submit all evidence within the 52-week statutory period for benefits
- Request a written explanation of the denial
- Seek legal advice if the insurer refuses to reconsider its decision
When to Seek Legal Advice
If your claim is denied and you're unsure how to proceed, consult a solicitor experienced in CTP claims. They can help you:
- Challenge the insurer's assessment of your injuries
- Request a review of the denial
- Explore options for disputing the decision
Final Steps After a Denial
After a denial, you should:
- Review the insurer's reasons in writing
- Gather additional evidence if needed
- Request a reconsideration within the 52-week period
- Seek legal assistance if the insurer refuses to reconsider
If you're in Auburn and need help with a denied CTP claim, contact LegalAdvice.com.au for a free, no obligation assessment of your circumstances.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.