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 Bankstown, you are not without recourse. Under the Motor Accident Injuries Act 2017, insurers must assess claims based on the law and evidence, not personal judgment. A denial does not end your rights. You have the right to challenge the decision through formal processes administered by the State Insurance Regulatory Authority (SIRA). The denial may relate to liability, the nature of your injuries, or the type of benefits claimed. It is critical to act promptly, as time limits apply to dispute and review processes.
Immediate Steps After a Denial
The first action is to obtain a written copy of the insurer’s decision. This document will state the reason for the denial and may include a reference to a policy clause or medical assessment. Do not delay. Within 28 days of receiving the denial, you must notify SIRA of your intention to dispute the decision. This is a formal step that starts the review process.
Next, preserve all evidence related to the accident and injury. This includes medical records, photographs of the scene or vehicle damage, witness contact details, and any correspondence with the insurer. If you were treated by a medical practitioner, obtain a copy of your treatment notes and a certificate of injury. These records are essential to support your claim and may be required in a review or formal dispute.
How SIRA’s Process Works for Denied Claims
SIRA oversees the CTP claims process in NSW. When a claim is denied, you may apply for a review through SIRA’s dispute resolution service. This process is free and does not require a solicitor. You must submit your application within 28 days of receiving the denial letter. SIRA will assess the evidence and may request further information from you or the insurer.
If the review does not resolve the dispute, you may apply to the Civil and Administrative Tribunal (NCAT) for a determination. NCAT is a specialist tribunal that hears motor accident claims. It can order the insurer to pay benefits, including treatment and care benefits, weekly income payments, or damages, if the law supports it. The tribunal will consider the evidence, medical reports, and applicable provisions of the Motor Accident Injuries Act 2017.
Evidence That Matters in Challenging a Denial
To successfully challenge a denial, you must provide clear and consistent evidence. The most critical items include:
- A medical certificate from a registered medical practitioner confirming the injury and its connection to the motor accident.
- A detailed record of treatment, including dates, procedures, and outcomes.
- Photographs of the accident scene, vehicle damage, or injury manifestations.
- Witness statements, if available, describing how the accident occurred.
- A copy of the police report, if one was filed.
- Documentation of any loss of income, including payslips or a letter from your employer.
SIRA’s guidelines state that a claim may be denied if the insurer believes the injury was not caused by the accident, or if the injury does not meet the threshold for damages. However, even if your injury is classified as a threshold injury, you may still be entitled to treatment and care benefits and weekly income payments under the CTP scheme.
Time Limits and Procedural Deadlines
Time is critical. You must notify SIRA of your intention to dispute a denial within 28 days of receiving the letter. Missing this deadline may prevent you from accessing a review or tribunal process. If you are unable to meet the deadline due to a valid reason, such as a serious illness or lack of access to legal advice, you may apply to SIRA for an extension. However, this is not guaranteed and must be supported by evidence.
If you proceed to NCAT, you must file your application within 12 months of the accident date, or within 12 months of the insurer’s final decision, whichever is later. This deadline is strict and cannot be extended without a compelling reason.
When to Seek Legal Advice
While you are not required to have a solicitor to dispute a claim, it is strongly advisable to seek independent legal advice if:
- The insurer denies liability and you believe the accident was not your fault.
- Your injury is complex or ongoing, and you need help interpreting medical reports.
- The insurer disputes your entitlement to damages, particularly if your injury is a threshold injury.
- You have been denied treatment and care benefits that you believe are necessary.
A solicitor can help you prepare a formal application, gather evidence, and represent you at a tribunal hearing. They can also advise on whether the claim should be pursued under the CTP scheme or if a common law damages claim may be viable.
Realistic Example: A Cyclist’s Claim in Bankstown
A cyclist in Bankstown was struck by a car while riding on a shared path. The insurer denied the claim, stating the injury was not caused by the accident and that the cyclist had a pre-existing condition. The cyclist obtained a medical certificate confirming a soft-tissue injury to the neck, supported by MRI results showing a disc bulge. The cyclist also provided a witness statement and photographs of the scene. After notifying SIRA within 28 days, the claim was reviewed and the insurer was ordered to pay treatment and care benefits and weekly income payments. The case was resolved without a tribunal hearing.
Next Steps for Injured Road Users in Bankstown
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.