Understanding Your Rights When a CTP Claim Is Denied 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 Compulsory Third Party (CTP) claim has been denied, you have formal processes to challenge the decision, particularly in rural and remote areas of New South Wales. The State Insurance Regulatory Authority (SIRA) oversees the CTP scheme and provides dispute resolution pathways to ensure fair outcomes. This article explains how to respond to a denial, what evidence to collect, and how to use SIRA’s processes to seek resolution.
How the CTP Scheme Works and Why Claims Are Denied
CTP claims in NSW are governed by the Motor Accident Injuries Act 2017 and administered by SIRA. Insurers must pay benefits for eligible injuries, including treatment and care, weekly income payments, and lump sum damages where injury thresholds are met. A claim may be denied if the insurer disputes liability, considers the injury ineligible, or believes benefits have been overpaid.
In rural and remote areas, access to legal and medical support may be limited, but SIRA offers services through its contact centres and local offices. If your claim was denied, the insurer must provide written reasons for the decision, including the basis for the denial and the right to request an internal review.
Steps to Challenge a Denied Claim
To dispute a CTP claim denial, follow these steps:
- Request an internal review from the insurer within 28 days of receiving the denial letter. The insurer must respond within 28 days.
- If the internal review upholds the denial, you may escalate the matter to the Personal Injury Commission (PIC) within 28 days of the review decision.
- Submit a formal dispute application to the PIC using the forms available on the SIRA website. Include all relevant evidence, such as medical reports, accident documentation, and correspondence with the insurer.
- The PIC may order a medical assessment if there is a dispute about the nature or severity of your injury. This is common in cases involving soft-tissue injuries or psychological injuries that are not a recognised psychiatric illness.
Evidence That Supports a Dispute
The strength of your claim depends on the quality and relevance of your evidence. Gather:
- Medical records from your treating practitioner, including diagnosis and treatment plan
- A report from a medical expert confirming the injury and its link to the accident
- Accident details, including a police report if available, witness statements, and photographs of the scene or vehicle damage
- Proof of income loss, such as payslips or a letter from your employer
- All correspondence with the insurer, including the denial letter and any responses
SIRA provides templates for dispute submissions on its website. In remote areas, you may use video calls or visit a local SIRA office to submit documents, especially if travel is difficult.
Key Legal Principles and Time Limits
A threshold injury under the Motor Accident Injuries Act 2017 includes a soft-tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness. The Motor Accident Guidelines define the clinical criteria for these injuries, including for spinal nerve-root injuries that produce neurological signs other than radiculopathy.
If your only injuries are threshold injuries, weekly benefits and treatment and care benefits generally cease after 52 weeks, as provided under sections 3.11 and 3.28 of the Act. This does not apply if you have a permanent impairment or if you are pursuing a common law damages claim.
Time limits are critical. You have 28 days from the date of the insurer’s denial to request an internal review. If the review upholds the denial, you have 28 days from the review decision to apply to the PIC. Missing these deadlines may prevent you from accessing formal dispute resolution.
Accessing Support in Rural and Remote Areas
SIRA operates contact centres across NSW, including in regional and remote locations. You can call the SIRA helpline or use the online portal to report a denied claim and request assistance. SIRA also provides information and forms in plain language to help claimants understand their rights.
If you are unable to travel to a SIRA office, you may arrange a video call or send documents by post. SIRA staff can assist you in preparing your dispute submission and explain the process step by step.
What Happens After You Escalate to the PIC
The PIC will review your application and may request additional information. If a medical dispute exists, the PIC may appoint an independent medical assessor to evaluate your injury. The assessor’s report will be considered in determining whether you are entitled to benefits.
The PIC’s decision is binding on the insurer. If the PIC finds in your favour, the insurer must pay the benefits you are entitled to, including back payments if applicable.
Next Steps
Every claim depends on its own facts. The outcome of a dispute depends on the nature of your injury, the evidence available, and whether the insurer complied with SIRA’s rules. If your claim was denied, act promptly to request an internal review and seek advice if needed.
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