Understanding CTP Claim Denials in NSW
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 by an insurer in regional NSW, you are not without recourse. Insurers may deny claims on grounds such as lack of liability, absence of injury, or failure to meet statutory thresholds. However, the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017 establish a clear framework for disputing such decisions. The denial of a claim does not end your rights. You have the right to seek a review through formal dispute resolution processes administered by the State Insurance Regulatory Authority (SIRA).
Dispute Resolution Options Through SIRA
SIRA is the independent body responsible for overseeing CTP claims in NSW. If your claim is denied, you may request a review through SIRA’s dispute resolution process. This process is available to all claimants, including those in regional and remote areas. You can apply for a review if the insurer has declined liability, refused to pay benefits, or failed to provide treatment and care benefits.
SIRA’s dispute resolution process is designed to be accessible and impartial. It includes the opportunity to submit written submissions, provide evidence, and, if necessary, attend a conference or hearing. The process is not adversarial in nature, but it is formal and binding once finalised. The review will assess whether the insurer’s decision was reasonable and consistent with the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines.
Evidence That Supports a Dispute
To strengthen your dispute, you must gather and preserve evidence that supports your claim. This includes:
- Medical records from your treating practitioner, including diagnosis, treatment plan, and progress notes
- A completed accident report, if available, including details of the time, location, and circumstances
- Photographs of the accident scene, vehicle damage, or injury manifestations
- Witness statements, if available, detailing what they observed
- Proof of income loss, such as payslips or a letter from your employer
- Correspondence with the insurer, including written denials and responses
A key point under the Motor Accident Guidelines is that a claimant may still be entitled to benefits even if they have not been diagnosed with a threshold injury, provided they have sustained a permanent impairment or ongoing functional loss.
Time Limits for Disputing a Denial
Time is critical. You must apply for dispute resolution within 12 months of the insurer’s written decision denying your claim. This deadline is strict and not extendable under normal circumstances. If you miss the deadline, you may still apply to SIRA for an extension, but only if you can demonstrate a valid reason for the delay, such as illness, lack of access to legal advice, or communication failure.
The 12-month period begins from the date the insurer issued its final written denial. If you have not received a formal letter, you should request a written response from the insurer to confirm the denial and the date it was issued.
Internal Review and the Personal Injury Commission
Before approaching SIRA, you may request an internal review from the insurer. This is not mandatory but may resolve the issue quickly. If the insurer upholds the denial after internal review, you may then proceed to SIRA’s dispute resolution process.
If your claim involves a medical dispute, such as disagreement over the extent of injury, the presence of a threshold injury, or the need for ongoing treatment, you may apply to the Personal Injury Commission (PIC) for a medical assessment. The PIC provides independent medical evaluations to resolve disputes about injury status, impairment, and treatment needs. This process is available to all claimants, including those in regional NSW, and is designed to be accessible via teleconference or regional appointments.
When to Seek Legal Advice
While you are not required to have a solicitor to dispute a CTP claim, legal advice is strongly recommended in complex cases. You should consider seeking legal advice if:
- The insurer has denied liability based on a disputed fact, such as whether you were in a vehicle at the time of the accident
- You have sustained a serious or ongoing injury, including a spinal nerve-root injury with neurological signs
- The insurer has refused to pay treatment and care benefits despite medical evidence of need
- You believe the insurer has failed to act in good faith or has not followed the Motor Accident Guidelines
Legal advice can help you understand whether your claim meets the statutory criteria for benefits, how to structure your evidence, and whether to pursue a claim for damages in addition to statutory benefits.
A Realistic Example
Consider a regional NSW resident who was a passenger in a car that collided with a tree on a rural road. The driver was at fault, but the insurer denied the claim on the grounds that the injuries were not severe enough to qualify as threshold injuries. The claimant had ongoing neck pain, limited range of motion, and was prescribed physiotherapy. After gathering medical records and a specialist assessment confirming a spinal nerve-root injury with neurological signs, the claimant submitted a dispute to SIRA. SIRA reviewed the evidence and required the insurer to reinstate treatment and care benefits. The claimant later obtained a medical assessment through the PIC, which confirmed a whole person impairment of 10%. This enabled a claim for damages under the Motor Accident Injuries Act 2017.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.