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 an insurer denies your NSW Compulsory Third Party (CTP) claim, you may be unsure how to proceed. Common reasons for denial include disputes over injury severity, contributory fault, or eligibility for benefits. This article explains how to challenge a denial, what evidence to gather, and how SIRA's rules apply to claims in Newcastle and Hunter.
Common Reasons for CTP Claim Denials
Insurers often deny claims by arguing the injury does not meet the threshold injury definition under the Motor Accident Injuries Act 2017. For example, they may claim your soft tissue injury lacks neurological signs or does not involve spinal nerve-root damage. Other denials arise from disputes over contributory fault, where the injured person is found to have contributed to the accident. Insurers may also reject claims if they believe the injury is not a direct result of the motor accident.
How to Challenge a Denied CTP Claim
To challenge a denial, start by reviewing the insurer's reasons in their written response. If the denial relates to injury severity, request a reassessment by a medical practitioner approved by SIRA. You may also seek mediation through the NSW Civil and Administrative Tribunal (NCAT) if the insurer refuses to negotiate. For disputes over contributory fault, consult a legal professional to assess whether the insurer's position is legally sound.
Evidence Needed to Dispute a Denial
When disputing a denial, gather medical records confirming your injury, including reports from doctors or specialists. Accident reports, witness statements, and photographs of the scene can also support your claim. If the insurer disputes your income loss, provide payslips or tax records. SIRA's guidelines state that weekly income payments are available for 52 weeks if your only injuries are threshold injuries, so ensure your evidence clearly links your injuries to the accident.
SIRA's Role in Disputes
SIRA oversees the CTP scheme and provides resources to help claimants understand their rights. If an insurer denies a claim, SIRA may intervene to mediate or review the decision. In Newcastle and Hunter, claimants can contact SIRA directly to request a review of their case. The insurer must provide a written explanation for any denial, and you can use this as a basis to challenge the decision.
When to Seek Legal Advice
If the insurer refuses to reconsider its decision or if your claim involves complex issues like lifetime care or workers' compensation overlap, seek legal advice. A solicitor can help you navigate disputes, ensure you meet all eligibility criteria, and challenge the insurer's interpretation of the law. Remember, time limits apply, most CTP claims must be submitted within 52 weeks of the accident, though exceptions exist for certain injuries.
Example Scenario
Consider a claimant who suffered a soft tissue injury after a car accident in Newcastle. The insurer denied the claim, arguing the injury did not meet the threshold definition. The claimant then sought a second medical opinion, which confirmed the injury met the criteria. Using this evidence, the claimant successfully disputed the denial and received weekly income payments.
If you're facing a denied CTP claim, take action promptly. General information cannot determine whether a claim is available in an individual case. Complete the quick, no obligation enquiry form to request contact about your circumstances.