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, you have legal options to challenge the decision. Under NSW law, insurers must follow specific processes when disputing claims, and SIRA provides formal pathways to resolve disputes. This article explains your rights, the evidence that matters, and the steps to challenge a denied claim in Western Sydney.
What to Do When a CTP Claim is Denied
When an insurer denies your CTP claim, they must provide a written explanation. Common reasons include disputes over injury severity, fault, or eligibility. You are entitled to challenge this decision through:
- Internal insurer review: Most insurers offer a formal process to review denied claims. You must request this within 28 days of receiving the denial letter.
- SIRA dispute resolution: If the insurer refuses to reconsider or the dispute remains unresolved, you can escalate the matter to SIRA. SIRA will assess whether the insurer’s decision aligns with the Motor Accident Injuries Act 2017.
- Mediation or arbitration: SIRA may refer your case to mediation or arbitration if the dispute involves complex medical or legal issues.
How SIRA Handles CTP Disputes
SIRA administers the NSW CTP scheme and has specific rules for resolving disputes. When you escalate a claim to SIRA, they will:
- Review the insurer’s decision and supporting evidence
- Assess whether the claimant meets the legal definition of a 'threshold injury' or 'injury' under the Motor Accident Injuries Act 2017
- Consider medical reports, accident reports, and other evidence
If SIRA finds the insurer’s decision was incorrect, they may order the insurer to reconsider the claim. However, SIRA does not provide legal advice or make decisions about fault.
Practical Steps to Challenge a Denied Claim
To build a strong case, gather the following evidence:
- Medical records: Include all treatment documents, specialist reports, and opinions from your healthcare providers.
- Accident details: Provide a written statement, photos, and witness contact information.
- Insurer correspondence: Keep copies of all communication with the insurer.
- Income records: Show how the injury has affected your ability to work.
You must act quickly. Most CTP claims must be submitted within 52 weeks of the accident. If your claim is denied after this period, you may lose access to statutory benefits.
When to Seek Legal Advice
Disputes over denied CTP claims often involve complex legal and medical issues. For example, if your injury is classified as a 'threshold injury' but the insurer disputes this, you may need a lawyer to:
- Challenge the medical opinion used to deny your claim
- Navigate the SIRA dispute resolution process
- Ensure your rights under the Motor Accident Injuries Act 2017 are protected
Legal advice is especially important if your claim involves:
- Disputes over fault or contributory negligence
- Claims for long-term care or future injuries
- Conflicts between medical professionals' opinions
Example: Challenging a Denied Claim
Consider this scenario: A motorcyclist in Western Sydney is denied CTP benefits because the insurer claims their injury does not meet the 'threshold injury' definition. The claimant provides additional medical evidence showing spinal nerve-root damage with neurological signs, which SIRA rules qualifies as a threshold injury. The insurer must then reconsider the claim.
This example shows how medical evidence and legal interpretation can resolve disputes. However, each case is unique, and legal advice is essential to ensure your rights are protected.
Next Steps
CTP claim disputes depend on the accident date, injury type, and evidence submitted. To request contact about your circumstances, complete the quick, no obligation enquiry form.