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, you're not alone. Injured people in the Blue Mountains and Nepean often ask: Why was my claim rejected? How can I challenge this? What evidence do I need? This article explains the common reasons insurers deny claims, how SIRA handles disputes, and practical steps to take under NSW law.
Common Reasons Insurers Deny CTP Claims
Insurers may deny claims for several reasons. First, they might dispute whether the accident falls under the CTP scheme. For example, if the accident occurred on private property or involved a non-motor vehicle, the insurer could argue it doesn't qualify. Second, insurers may claim the injury doesn't meet the threshold injury definition under the Motor Accident Injuries Act 2017. This includes injuries like soft tissue damage, spinal nerve-root injuries, or whiplash, which require specific clinical signs to qualify.
Another reason is incomplete or unclear evidence. Insurers often request medical records, accident reports, and witness statements to verify the claim. If these documents are missing or inconsistent, the insurer may refuse to pay. For instance, if a claimant hasn't provided a doctor's report confirming the injury, the insurer might argue the claim lacks sufficient proof.
How SIRA Handles Disputes Over Denied Claims
SIRA (State Insurance Regulatory Authority) oversees CTP claims in NSW. If an insurer denies a claim, you can contact SIRA to escalate the issue. SIRA will review the claim and may request additional evidence from the insurer or the claimant. In some cases, SIRA will mediate between the parties to resolve the dispute.
SIRA also has a process for reviewing claims that have been denied by insurers. If you believe the denial is incorrect, you can submit a formal objection to SIRA. The authority will then investigate the claim and make a decision based on the evidence. This process ensures that claimants have a fair chance to challenge a denial.
Practical Steps to Challenge a Denied Claim
If your claim has been denied, take these steps: First, review the denial letter to understand the insurer's reasons. Next, gather any additional evidence that supports your claim. This could include medical records, accident reports, and witness statements. If you haven't already, consult a medical practitioner to confirm the injury and its impact on your daily life.
You should also contact SIRA to escalate the issue. SIRA will guide you through the process of challenging the denial and may request a review of the claim. It's important to act quickly, as there are time limits for disputing claims. For example, if your claim was denied after 52 weeks, you may need to provide new evidence to support your case.
Evidence Needed to Challenge a Denial
To challenge a denied claim, you'll need to provide clear evidence that supports your case. Medical records are crucial, as they document the nature and severity of your injury. Accident reports, witness statements, and photographs of the accident scene can also be helpful. If you've been receiving treatment, ensure that your medical records include details of your condition and how it affects your daily activities.
You should also keep records of any correspondence with the insurer, including emails and letters. These documents can help demonstrate that you've followed the correct procedures and that the insurer has not acted fairly. If you're unsure about the evidence you need, SIRA can provide guidance on what to submit.
When to Seek Legal Advice
If you're struggling to challenge a denied claim, consider seeking legal advice. A solicitor can help you understand your rights and the best way to proceed. They can also assist with drafting formal objections to the insurer and representing you in disputes with SIRA. Legal advice is particularly useful if the insurer is uncooperative or if the claim involves complex legal issues.
Time Limits and Next Steps
It's important to act quickly when your claim is denied. There are time limits for disputing claims, and delays can affect your ability to challenge the denial. If your claim was denied after 52 weeks, you may need to provide new evidence to support your case. SIRA will guide you through the process of challenging the denial and may request a review of the claim.
If you're unsure about the next steps or need help challenging a denied claim, contact SIRA directly. They can provide guidance on what to do and may help you resolve the dispute.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.