How 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 disputing liability, disputing the nature of injuries, or arguing that benefits are not payable. Common reasons include claims that injuries fall below the 'threshold injury' definition, disputes over fault, or failure to meet specific eligibility criteria. For example, an insurer may deny a claim if the injured person’s injuries are deemed to be 'soft tissue' injuries without meeting the spinal nerve-root qualification outlined in the Motor Accident Guidelines.
Practical Steps for Claimants in Auburn
If your CTP claim is denied, take these steps to challenge the decision:
- Review the denial letter: Insurers must provide a clear reason for the denial, such as a lack of evidence or a dispute over injury severity.
- Gather evidence: Medical records, accident reports, witness statements, and photographs are critical. For instance, if the insurer disputes the injury’s severity, provide documentation from a medical practitioner confirming the injury meets the threshold injury definition.
- Contact the insurer’s dispute resolution team: SIRA’s guidelines require insurers to resolve disputes through their internal processes before escalating to SIRA.
- Seek independent medical assessment: If the insurer questions the injury’s nature, request an independent assessment to confirm the injury meets the required criteria.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident, unless the injury was not immediately apparent. If the insurer denies a claim, you have 28 days to dispute the decision under the Motor Accident Injuries Act 2017. If the insurer fails to resolve the dispute within this timeframe, you may escalate the matter to SIRA.
SIRA’s Role in Resolving Disputes
SIRA (State Insurance Regulatory Authority) oversees CTP claims and resolves disputes between claimants and insurers. If an insurer denies a claim, SIRA may:
- Review the claim: Assess whether the insurer’s denial is justified based on the evidence.
- Mediate: Facilitate discussions between the claimant and insurer to reach a resolution.
- Issue a binding decision: If the dispute cannot be resolved, SIRA may determine whether the claim is payable.
Example: Challenging a Threshold Injury Denial
Consider a claimant in Auburn who was in a car accident and sustained a soft tissue injury. The insurer denies the claim, arguing the injury does not meet the threshold injury definition. The claimant can challenge this by:
- Providing medical records confirming the injury meets the spinal nerve-root qualification.
- Submitting a report from a medical practitioner explaining how the injury meets the Motor Accident Guidelines.
- Requesting a review by SIRA if the insurer refuses to reconsider the claim.
When to Seek Legal Advice
If the insurer’s denial is based on complex legal or medical issues, such as disputes over contributory fault or overlapping workers’ compensation claims, it may be necessary to seek legal advice. A solicitor can help you navigate the process, ensure all evidence is properly submitted, and challenge the insurer’s decision if it is legally unsound.
Next Steps
CTP claims depend on the specific facts of each case. If you are in Auburn and facing a denied claim, take action promptly to preserve your rights. Complete the quick, no obligation enquiry form to request contact about your circumstances.