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 in New South Wales, you may need to prove your injury meets the scheme's requirements. The Motor Accident Injuries Act 2017 (MAIA) and SIRA guidelines outline what documentation is needed to challenge a denial. This article explains the key evidence to compile, how SIRA's standards apply, and steps to take when facing a rejected claim.
Legal Framework for CTP Claims
NSW's Compulsory Third Party (CTP) scheme under the MAIA governs claims for injuries caused by motor vehicle accidents. SIRA (State Insurance Regulatory Authority) administers the scheme, setting rules for what injuries qualify and how claims are processed. Insurers must assess claims against these criteria, including medical evidence of injury severity.
Essential Documentation to Challenge a Denied Claim
When an insurer rejects a claim, you must demonstrate that your injury meets the scheme's definition of a 'threshold injury' or higher. Key documentation includes:
- Medical records: Detailed reports from doctors confirming the injury's nature, onset date, and treatment. SIRA's guidelines emphasize that injuries must be 'sufficiently serious' to qualify.
- Incident reports: Police reports, witness statements, and accident scene photos to establish the event's circumstances.
- Medical opinion: A specialist's assessment linking the injury to the accident, especially for soft-tissue injuries requiring spinal nerve-root qualification under the guidelines.
- Income records: Proof of lost wages or reduced earning capacity if claiming weekly benefits.
- Correspondence: Copies of all insurer communications to track the claim's progress.
How SIRA Guidelines Apply to Disputed Claims
SIRA's 'What you can claim' page clarifies that benefits are limited to injuries meeting the MAIA's threshold. For example, if your injury is classified as a 'threshold injury' (e.g., a minor soft-tissue injury), weekly benefits typically stop after 52 weeks. Insurers may deny claims if documentation fails to prove the injury's severity or duration.
Steps to Take When a Claim is Denied
- Review the denial letter: Identify the specific reason for rejection, such as insufficient medical evidence or failure to meet the threshold injury definition.
- Gather additional evidence: Consult a medical practitioner to obtain a fresh assessment or request a second opinion.
- Submit a formal dispute: Use the insurer's internal review process, referencing SIRA's guidelines to support your case.
- Seek independent advice: If the insurer persists, contact a legal professional to explore options like mediation or tribunal review.
Time Limits and Dispute Options
Claims must be submitted within 52 weeks of the accident, though extensions may apply for serious injuries. If an insurer denies a claim without valid reasoning, you may need to escalate the matter through SIRA's dispute resolution process or the NSW Civil and Administrative Tribunal (NCAT).
When to Seek Legal Advice
If your claim is denied and you're unsure how to respond, consult a solicitor specialising in CTP claims. They can help you interpret SIRA's requirements, challenge the insurer's decision, and ensure you meet all procedural deadlines.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.