How NSW CTP Insurers Evaluate Returning to Daily Activities in Claim Denials
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).
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
If your CTP claim has been denied on the grounds that you’ve resumed daily activities, understanding how insurers assess this is critical. NSW insurers rely on the Motor Accident Injuries Act 2017 and SIRA guidelines to determine whether a claimant meets the threshold for benefits. This article explains the legal standards insurers apply, the evidence they require, and steps to challenge a denial.
Legal Standards for Assessing Daily Activity Resumption
NSW CTP insurers evaluate whether a claimant has returned to their pre-accident level of function using the Motor Accident Guidelines. Key factors include:
- Medical evidence: Doctors must document whether the claimant can perform daily activities without restrictions. This includes mobility, cognitive function, and physical capacity.
- Clinical signs: For soft-tissue injuries, insurers require evidence of neurological signs (e.g., radiculopathy) to confirm injury severity.
- Activity logs: Claimants must provide records of their daily routine, such as work hours, household tasks, or social engagements, to demonstrate functional capacity.
Insurers may also consider SIRA’s definition of 'threshold injury' (injuries requiring medical treatment but not resulting in long-term impairment). If your injury falls below this threshold, benefits may be limited.
Evidence to Prove Daily Activity Resumption
To challenge a denial, gather the following:
- Medical records: Include reports from your GP, specialists, or physiotherapists confirming your ability to perform daily activities.
- Activity logs: Keep a diary of your routine, noting tasks like cooking, shopping, or work hours.
- Witness statements: Testimonies from family, colleagues, or friends about your functional capacity.
- Employment records: Proof of work attendance or modified duties if you’ve returned to work.
For example, if you were denied benefits because you’ve resumed work, but your doctor notes ongoing fatigue or pain, this could challenge the insurer’s assessment.
Disputing a Denial and Time Limits
If your claim is denied, you can:
- Submit additional evidence to the insurer, such as updated medical reports or activity logs.
- Request a review under the Motor Accident Injuries Act 2017 s 4.4, which allows for reassessment of benefits.
- Seek independent medical advice to challenge the insurer’s interpretation of your condition.
Be aware of time limits: Benefits for threshold injuries are generally limited to 52 weeks under s 3.28 of the Motor Accident Injuries Regulation 2017. If your injury falls below this threshold, benefits may stop after 52 weeks.
When to Seek Legal Advice
Insurers may deny claims based on subjective interpretations of your daily activities. If your claim is denied and you believe the decision is unfair, consider consulting a solicitor. They can help you:
- Challenge the insurer’s reliance on incomplete or misleading evidence.
- Navigate the 52-week benefits cap.
- Pursue a dispute through the NSW Civil and Administrative Tribunal (NCAT) if necessary.
Next Steps
CTP claim denials based on daily activity resumption depend on the specific facts of your case. To request contact about your circumstances, complete the quick, no obligation enquiry form.