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 in New South Wales, you have legal options to challenge the decision. This article explains how to dispute a denied CTP claim, including the steps to take and the role of the State Insurance Regulatory Authority (SIRA) in resolving disputes. The NSW CTP scheme governs these processes, and understanding your rights is critical to pursuing compensation.
How to Challenge a Denied CTP Claim
When an insurer denies a CTP claim, the first step is to request an internal review. Most insurers have a process to reassess decisions based on new evidence or clarification. Under the Motor Accident Injuries Act 2017, you must notify the insurer of your intent to dispute within 28 days of receiving the denial letter. This period is strictly enforced, and missing it may limit your options.
If the insurer’s internal review upholds the denial, you may escalate the matter to the Personal Injury Commission (PIC). The PIC oversees disputes about claim eligibility and benefits. You can apply for a review of the insurer’s decision by submitting a written request to the PIC within 28 days of the internal review outcome. The PIC will assess whether the insurer applied the CTP scheme correctly, including whether your injuries meet the threshold injury definition under the Motor Accident Guidelines.
SIRA’s Role in Disputes
SIRA provides guidance on resolving disputes, including templates for written submissions. If the PIC does not resolve the issue, you may need to escalate the matter to the NSW Civil and Administrative Tribunal (NCAT) or the District Court. However, these higher-level options are typically reserved for complex cases, such as disputes over long-term impairment assessments or claims involving multiple insurers.
Practical Steps to Take
To challenge a denied claim, gather evidence that supports your case. This includes:
- Medical records confirming your injuries
- Accident reports or witness statements
- Proof of income to support claims for weekly payments
- Correspondence with the insurer showing the denial
You should also seek clarification on why the insurer denied your claim. For example, if the insurer claims your injuries are not threshold injuries, request a detailed explanation of their assessment. This can help identify gaps in their reasoning or errors in applying the CTP scheme.
Time Limits and When to Seek Advice
Time is critical. Under the CTP scheme, you have 28 days to request an internal review and another 28 days to apply for a PIC review. Missing these deadlines may prevent you from challenging the insurer’s decision. If you are unsure about your options or need help preparing a dispute, seek legal advice promptly. A solicitor can help you navigate the process and ensure your rights are protected.
Example Scenario
Consider a case where a pedestrian’s claim is denied because the insurer claims the injuries are not threshold injuries. The injured person requests an internal review, provides additional medical evidence, and then applies to the PIC. The PIC finds the insurer’s initial assessment was incorrect and orders the claim to be reconsidered. This shows how structured dispute steps can lead to a positive outcome.
Next Steps
CTP claim disputes depend on the date of the accident, the nature of the injury, and the insurer’s decision-making process. If you are unsure how to proceed, complete the quick, no obligation enquiry form to request contact about your circumstances. Every claim depends on its own facts, and the right approach can make a difference.