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 Compulsory Third Party (CTP) claim has been denied by an insurer in NSW, you have options to challenge the decision. This article explains how to dispute a denied CTP claim, including SIRA's role, alternative dispute resolution pathways, and when to seek legal advice. The process depends on the nature of the denial, evidence you can provide, and time limits under NSW law.
What to Do When a CTP Claim is Denied
Under NSW law, insurers must pay benefits if a claim meets the criteria in the Motor Accident Injuries Act 2017. If your claim is denied, you can:
- Request a review with the insurer
- Contact SIRA to escalate the matter
- Seek mediation through the Personal Injury Commission
- Apply for a review by the NSW Civil and Administrative Tribunal (NCAT)
The insurer must provide a written explanation for the denial. If they refuse to pay, you can challenge their decision using the formal dispute process.
How SIRA Handles Disputes
SIRA oversees CTP claims and has specific procedures for resolving disputes. If your claim is denied, you should:
- Submit a written request for a review to the insurer, clearly stating your disagreement
- Contact SIRA to escalate the matter. They will review the insurer's decision and may request additional evidence
- Provide medical evidence showing your injuries meet the threshold injury definition under the Motor Accident Guidelines
SIRA does not provide legal advice but will assess whether the insurer's decision complies with the law. If they find the insurer was incorrect, they can order payment.
Alternatives to SIRA Mediation
If SIRA mediation does not resolve the dispute, you can:
- Apply for a review by NCAT - The tribunal can review the insurer's decision and order payment if they find the claim is valid
- Seek legal assistance - A solicitor can help you prepare evidence and apply for a review
Note: You must act within time limits. Most claims must be submitted within 52 weeks of the accident, though exceptions exist for certain injuries.
Practical Steps to Take
To challenge a denied CTP claim, gather:
- Medical records showing your injuries meet the threshold injury definition
- Accident reports from police or witnesses
- Photographs of the scene and vehicle damage
- Income records to support claims for weekly benefits
- Correspondence with the insurer showing their refusal to pay
You should also keep copies of all documents and follow up in writing. If the insurer refuses to provide a written explanation for the denial, this can support your case.
When to Seek Legal Advice
Consider consulting a solicitor if:
- The insurer denies liability without a valid reason
- You are unsure whether your injuries qualify for benefits
- You need help preparing evidence for a review
- You want to challenge the insurer's interpretation of the law
A solicitor can help you understand your options and prepare a strong case for review by SIRA or NCAT.
Example Scenario
A cyclist in Auburn was injured in a collision and claimed weekly benefits. The insurer denied the claim, arguing the injuries were not 'threshold injuries'. The cyclist submitted medical records showing a spinal nerve-root injury with neurological signs, which met the threshold injury definition under the Motor Accident Guidelines. SIRA reviewed the evidence and ordered the insurer to pay the benefits.
Next Steps
CTP claim disputes depend on the specific facts of your case. If your claim has been denied, you should act quickly to challenge the decision. For personalized advice, complete the quick, no obligation enquiry form to request contact about your circumstances.