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).
If your CTP claim has been denied by an insurer in Ballina, you need to understand your rights and what evidence to retain. Under NSW law, insurers must provide a written explanation for denying claims. This article explains how to respond to a denial, what records to keep, and when to seek legal advice.
What Evidence to Keep When a CTP Claim is Denied
When an insurer denies your claim, retaining specific evidence is critical. Key documents include:
- Medical records showing injuries and treatment (e.g., GP notes, scans, specialist reports)
- Accident reports from police or witnesses detailing the incident
- Witness statements confirming the accident and fault
- Photographs of the scene, vehicle damage, and injuries
- Correspondence with the insurer, including denial letters
- Income records to support claims for lost wages or care costs
SIRA guidelines require insurers to assess claims based on objective evidence. If your claim is denied, review the insurer's reasoning against your records. For example, if the insurer disputes a threshold injury, ensure your medical evidence meets the spinal nerve-root qualification under the Motor Accident Guidelines.
How SIRA's Guidance Applies to Denied Claims
SIRA's Motor Accident Claims page explains that insurers must provide a written notice of denial within 28 days. If the denial relates to a threshold injury (e.g., soft tissue injury), the Motor Accident Injuries Act 2017 s 4.4 limits benefits after 52 weeks. However, this applies only if the injury is your 'only injury' from the accident. If you have additional injuries, benefits may continue beyond 52 weeks.
When an insurer denies a claim, they must specify whether the denial relates to:
- Fault (e.g., the accident wasn't caused by the insured vehicle)
- Eligibility (e.g., the injury doesn't meet threshold criteria)
- Time limits (e.g., benefits have expired)
If the insurer's reasoning is unclear or disputed, you may need to request a review under s 3.28 of the Motor Accident Injuries Regulation 2017.
Steps to Take After a CTP Claim is Denied
- Request a written explanation from the insurer detailing why the claim was denied
- Review SIRA's claim guidelines to ensure the insurer's decision aligns with the law
- Seek a second medical opinion if the injury assessment is contested
- Submit a formal dispute if the denial is based on incorrect information
- Consult a solicitor if the insurer refuses to reconsider the claim
If the insurer denies your claim without a valid reason, you may have grounds to challenge the decision. For example, if the denial is based on an incorrect assessment of your injury's severity, a solicitor can help you request a review under the Motor Accident Injuries Act 2017.
Time Limits and When to Seek Advice
CTP claims must be submitted within 28 days of the accident. However, if the insurer denies the claim, you may have additional time to challenge the decision. For instance, if the denial relates to a threshold injury, you can still seek a review under s 3.28 of the Regulation 2017.
If the insurer's denial is based on incorrect information or a misinterpretation of the law, it's important to act quickly. A solicitor can help you:
- Challenge the insurer's assessment of your injury
- Request a review of the claim decision
- Explore options for disputing the denial
When to Seek Legal Advice
Consider consulting a solicitor if:
- The insurer denies the claim without a clear explanation
- The denial relates to a disputed injury assessment
- You're unsure whether the claim meets SIRA's criteria
- You need help challenging the insurer's decision
A solicitor can help you understand your options and ensure the insurer complies with the law. They can also assist with submitting a formal dispute or requesting a review under the Motor Accident Injuries Act 2017.
Final Steps After a CTP Claim is Denied
If your CTP claim has been denied, take the following steps:
- Retain all evidence related to the claim
- Request a written explanation from the insurer
- Review SIRA's guidelines to ensure the denial is lawful
- Seek a second medical opinion if needed
- Consult a solicitor to challenge the denial if necessary
By following these steps, you can protect your rights and ensure the insurer complies with the law. If you're unsure how to proceed, complete the quick, no obligation enquiry form to request contact about your circumstances.