If an insurer denies your CTP claim because you're returning to daily activities, you're not alone. Insurers often challenge claims by arguing that injuries are not severe enough to meet compensation thresholds. In regional NSW, including the Illawarra and South Coast, claimants must prove their injuries meet the legal definition of a 'threshold injury' or demonstrate ongoing impairment. This article explains how insurers deny claims, what evidence you need to challenge denials, and how SIRA's framework applies to disputes over daily activities.
How Insurers Deny CTP Claims Related to Daily Activities
Insurers may deny claims by arguing that claimants have returned to work, school, or household duties, implying their injuries are not severe. Under the Motor Accident Injuries Act 2017, a 'threshold injury' requires a spinal nerve-root injury producing neurological signs or radiculopathy with specific clinical signs. If your injury doesn't meet this definition, insurers may argue you're not entitled to ongoing benefits.
For example, if you're recovering from a soft tissue injury but have returned to work, an insurer might claim you've 'recovered' and are no longer eligible for weekly payments. However, SIRA's guidelines clarify that even minor injuries requiring treatment qualify for statutory benefits, provided they meet the threshold criteria.
Evidence to Challenge a CTP Claim Denial
To dispute a denial, you must provide evidence that your injury meets the legal definition of a threshold injury or that you're still unable to perform daily activities. Key evidence includes:
- Medical records showing treatment for the injury, including imaging or specialist reports
- Doctor's notes confirming ongoing impairment or restrictions
- Accident reports detailing the incident and its severity
- Witness statements or photos of the accident scene
- Income records showing reduced earnings if you're unable to work
Insurers may also dispute claims by challenging the credibility of medical assessments. If your treating doctor's opinion conflicts with an insurer's independent assessment, you should request a second opinion from a SIRA-registered medical expert.
SIRA's Guidance on Daily Activities and Claim Disputes
SIRA's guidelines state that claimants must demonstrate a 'loss of function' or 'impairment' to qualify for ongoing benefits. If you've returned to daily activities but still experience pain or limited mobility, you may still be eligible for treatment and care benefits under the 52-week statutory scheme.
For example, if you're managing household duties but require pain medication, this could support a claim for weekly benefits. However, if your injury is classified as a 'threshold injury' under the Motor Accident Guidelines, insurers may argue you've reached maximum medical improvement after 52 weeks.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident, but this doesn't mean you must wait until that deadline to seek assistance. If an insurer denies your claim, you should contact SIRA or a legal advisor immediately. Delays can result in lost benefits, especially if your injury requires ongoing treatment.
In regional areas like the Illawarra and South Coast, claimants may face additional challenges accessing legal resources. SIRA provides a free claims assistance program, but you must apply within 52 weeks of the accident. If you're unsure whether your claim meets the threshold injury criteria, seek advice before submitting a dispute.
Next Steps
If an insurer denies your CTP claim, you're not without options. SIRA's framework allows claimants to challenge denials by providing evidence of ongoing impairment or treatment needs. However, the legal process can be complex, especially in regional NSW where access to legal resources may be limited. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.