When an insurer denies a Compulsory Third Party (CTP) claim in New South Wales, the burden shifts to the claimant to provide clear and comprehensive evidence that supports the injury and its connection to the motor accident. This is particularly important in Greater Sydney, where traffic density and complex accident circumstances can complicate claims. The denial may be based on disputed liability, perceived lack of injury, or failure to meet statutory thresholds. However, a denial does not end the process. Under the Motor Accident Injuries Act 2017 (MAIA), claimants have a right to challenge the decision and seek entitlement to benefits, including treatment and care, weekly income payments, and, where applicable, damages.
The foundation of any successful challenge lies in a well-structured injury documentation checklist. Insurers often deny claims on the basis of insufficient medical evidence, incomplete accident reporting, or failure to demonstrate a causal link between the accident and the injury. To counter this, claimants must gather and preserve evidence that meets the standards set by the State Insurance Regulatory Authority (SIRA) and the Motor Accident Injuries Regulation 2017.
Key medical documentation includes:
- A written report from a treating medical practitioner confirming the diagnosis, treatment plan, and the nature and extent of the injury.
- Diagnostic imaging results (X-rays, MRI, CT scans) with a radiologist’s interpretation, particularly for spinal or musculoskeletal injuries.
- A record of all medical appointments, including dates, symptoms reported, and any changes in condition.
- A functional capacity assessment, if the injury affects mobility, work capacity, or daily activities.
- For claims involving a threshold injury (such as a soft tissue injury), documentation must show that the injury meets the statutory definition, including any neurological signs beyond radiculopathy, as specified in the Motor Accident Guidelines.
In addition to medical records, claimants should compile:
- A detailed accident report, including the date, time, location, weather, road conditions, and a description of how the accident occurred.
- Photographs of the vehicle damage, scene conditions, and any visible injuries at the time of the accident.
- Witness statements, if available, including contact details and a written account of what they observed.
- A record of lost income, including payslips, a letter from the employer, and details of any time off work.
- Correspondence with the insurer, including claim forms, denial letters, and responses to requests for information.
Common reasons for CTP claim denials in NSW include:
- The insurer disputes liability, particularly in cases involving complex intersections, driver error, or multiple vehicles.
- The injury is not considered a threshold injury under MAIA, meaning it does not meet the criteria for damages, and the claimant may only be entitled to limited benefits.
- The claimant failed to notify the insurer within 28 days of the accident, which may affect eligibility for weekly payments.
- The insurer argues that the injury pre-existed the accident or was caused by a separate incident.
To address these, claimants must demonstrate a clear causal link between the accident and the injury. This includes showing that the injury was not present before the accident and that symptoms began shortly after. Where a claimant has a pre-existing condition, medical evidence must clarify whether the accident aggravated or worsened the condition.
If the insurer denies the claim, the next step is to request a formal review under SIRA’s dispute resolution process. The claimant may also apply to the Civil and Administrative Tribunal (NCAT) for a determination on entitlement. These processes require all documentation to be submitted in a structured and timely manner. Delays in providing evidence can result in further delays or even dismissal of the claim.
A realistic example: A pedestrian in Sydney’s Inner West was struck by a car at a crosswalk in July 2024. The insurer denied the claim, stating the injury (a minor neck strain) was not a threshold injury and did not justify damages. The claimant provided a full medical record showing an MRI confirmed a disc bulge, a functional assessment showing limited neck movement, and a treating doctor’s report linking the injury to the impact. The claim was later approved for treatment and care benefits and, after review, for damages due to the presence of a threshold injury with neurological signs.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.