Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
If your CTP claim has been denied due to alleged inability to return to daily activities, you're not alone. Insurers in NSW assess claimants' capacity to perform routine tasks as part of their evaluation. This article explains how insurers evaluate daily activity claims under the Motor Accident Injuries Act 2017, referencing SIRA guidelines and practical steps to challenge denials.
How Insurers Assess Daily Activity Claims
Insurers determine whether a claimant can return to daily activities by reviewing medical evidence and functional capacity assessments. Under the Motor Accident Injuries Act 2017, claimants must demonstrate that their injuries prevent them from performing ordinary tasks like cooking, shopping, or managing personal hygiene.
SIRA guidelines require insurers to consider whether the claimant's injuries meet the 'threshold injury' criteria. For example, a soft tissue injury must involve a spinal nerve-root injury with neurological signs. Insurers may also assess whether the claimant's condition aligns with the 'whole person impairment' threshold, which requires a 10% or greater impairment rating.
Practical Steps for Claimants
If your claim is denied, start by requesting the insurer's full assessment report. This document will outline their reasoning and the evidence they used to determine your capacity to return to daily activities. Compare this with your medical records to identify discrepancies.
Gather evidence showing your ability to perform daily tasks. This may include:
- Doctor's notes detailing your functional limitations
- Statements from family members or carers about your daily routine
- Evidence of your ability to manage household tasks (e.g., cooking, cleaning)
- Any work-related evidence showing your capacity to work
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident under the Motor Accident Injuries Act 2017. If your claim is denied after this period, you may need to pursue a common law damages claim instead.
To dispute a denial, you can:
- Request a review of the insurer's decision within 28 days of receiving the denial letter
- Submit additional medical evidence to support your claim
- Seek independent medical opinion if the insurer's assessment is contested
When to Seek Legal Advice
If your claim is denied and you believe the insurer's assessment is incorrect, consider consulting a legal professional. A solicitor can help you:
- Challenge the insurer's interpretation of your medical records
- Pursue a common law claim if your injury meets the threshold for damages
- Navigate the 52-week time limit for statutory benefits
Example Scenario
Imagine a claimant who suffered a soft tissue injury in a car accident on the Central Coast. The insurer denies benefits, claiming the claimant can return to daily activities. However, the claimant's doctor notes they experience chronic pain preventing them from lifting groceries. This medical evidence could challenge the insurer's assessment.
Next Steps
CTP claim denials can be complex, especially when they involve daily activity assessments. Always ensure your claim includes evidence of your functional limitations. If your insurer denies your claim, contact the quick, no obligation enquiry form to discuss your options.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.