Why Insurers Deny CTP Claims in NSW
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).
Insurers often deny Compulsory Third Party (CTP) claims in New South Wales by arguing the claimant does not meet scheme eligibility rules. This typically happens when the injury type, accident date, or claimant circumstances fall outside the Motor Accident Injuries Act 2017’s criteria. For example, insurers may reject claims for soft tissue injuries unless specific neurological signs are documented, or deny benefits if the injury is deemed a 'threshold injury' under the Motor Accident Guidelines.
Key Factors in Scheme Eligibility
Insurers assess eligibility based on three core factors:
- Nature of the injury, Must meet the 'threshold injury' definition in the Motor Accident Guidelines. Soft tissue injuries must involve spinal nerve-root damage with neurological signs, not just radiculopathy.
- Accident date, Claims for accidents before 1 July 2018 fall under the old scheme, while newer claims are governed by the 2017 Act. This distinction affects benefit limits and timeframes.
- Claimant circumstances, The injury must result directly from the motor accident. For example, pre-existing conditions or injuries from non-motor vehicle incidents are excluded.
Proving Eligibility When Denied
If an insurer rejects a claim, the claimant must:
- Review the Motor Accident Guidelines to verify if the injury meets the threshold definition. SIRA’s 'What you can claim' page outlines injury types covered.
- Provide medical evidence, Doctors must document neurological signs like sensory loss or reflex changes, not just pain or restricted movement.
- Submit accident details, Police reports, witness statements, and photographs help prove the injury resulted from the motor accident.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the injury, unless the injury is not 'threshold' and the claimant is seeking only statutory benefits. For disputes, claimants can:
- Request a review by the insurer’s internal appeals process
- Lodge a complaint with the NSW Civil and Administrative Tribunal (NCAT) if the insurer ignores the claim
- Seek independent medical assessment to challenge the insurer’s injury classification
Example: Soft Tissue Injury Denial
Consider a pedestrian in Western Sydney who suffered a soft tissue injury after being hit by a car. The insurer may deny benefits if the doctor only notes pain and restricted movement, without documenting neurological signs like sensory loss. The claimant must then request a second opinion to prove the injury meets the threshold definition.
When to Seek Legal Advice
CTP eligibility rules are complex and depend on the accident date, injury type, and claimant history. If an insurer denies a claim without clear reasoning, it’s essential to consult a solicitor specialising in NSW CTP claims. Legal professionals can help challenge unjust rejections and ensure all evidence meets the scheme’s requirements.
Next Steps
CTP entitlements depend on the specific facts of each case. To request contact about your circumstances, complete the quick, no obligation enquiry form.