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 is denied by an insurer in regional NSW, retaining the right evidence is critical. Under the Motor Accident Injuries Act 2017, insurers must provide a written explanation for claim rejections. This article explains which records to preserve, how to challenge decisions using SIRA guidelines, and steps to take when your claim is denied.
Why Insurers Deny CTP Claims
Insurers may reject claims due to incomplete evidence, disputes over injury severity, or failure to meet statutory thresholds. For example, a claimant with soft-tissue injuries (threshold injuries) may face reduced benefits after 52 weeks under s 4.4 of the Motor Accident Injuries Act 2017. Always request a written explanation of the denial, as this forms the basis for disputing the decision.
Evidence to Preserve
- Medical Records: Keep all injury assessments, treatment notes, and specialist reports. SIRA guidelines (https://www.sira.nsw.gov.au/claims/motor-accidents/what-you-can-claim) clarify that injuries must meet specific clinical criteria to qualify for benefits.
- Accident Details: Document the incident with police reports, witness statements, and photos of the scene. In regional NSW, local police may have limited resources, so thorough documentation is essential.
- Insurer Correspondence: Save all emails, letters, and phone records from the insurer. SIRA requires insurers to provide a written response within 28 days of a claim submission (s 3.28 of the Motor Accident Injuries Regulation 2017).
- Income and Expenses: Retain payslips, bank statements, and receipts for out-of-pocket costs. These support claims for weekly income payments or treatment and care benefits.
Using SIRA Guidelines to Challenge Denials
SIRA’s Motor Accident Claims page (https://www.sira.nsw.gov.au/claims/motor-accidents) outlines how to dispute decisions. If an insurer rejects a claim for threshold injuries, you can:
- Request a review of the injury assessment.
- Submit additional medical evidence to demonstrate the injury meets the spinal nerve-root qualification (per the Motor Accident Guidelines).
- Appeal to the NSW Civil and Administrative Tribunal (NCAT) if the insurer refuses to reconsider.
Documenting the Denial Process
Create a timeline of all communications with the insurer. For example, if an insurer denies a claim for a fractured wrist (a threshold injury), you can challenge the decision by:
- Example: A claimant in Dubbo retained medical records showing persistent pain and limited mobility, which the insurer initially overlooked. By submitting a revised injury assessment, they secured a review of their weekly income payment.
Time Limits and Next Steps
CTP claims must be submitted within 28 days of the accident (s 3.28). If the insurer denies your claim, you have 28 days to request a written explanation. If the denial is based on a threshold injury, you may need to wait until the 52-week period to challenge the benefits cap. Always seek legal advice if the insurer refuses to engage with your evidence.
When to Seek Help
If your insurer ignores your request for a review, or if you’re unsure whether your injury qualifies, contact a solicitor specialising in CTP claims. Regional NSW has limited legal resources, so early intervention is key to preserving your entitlements.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.