Why Do Insurers Deny CTP Claims in NSW?
New South Wales insurers often deny Compulsory Third Party (CTP) claims due to disputes over injury severity, fault, or evidence. Common reasons include claims for soft tissue injuries falling below the threshold, disputes over contributory fault, or lack of medical documentation. Injured claimants in Illawarra and South Coast should understand these legal bases and how to respond.
Common Reasons for CTP Claim Denials
- Threshold Injury Disputes: Under the Motor Accident Injuries Act 2017, only injuries meeting the 'threshold injury' definition qualify for benefits. SIRA guidelines specify that soft tissue injuries must involve spinal nerve-root damage with neurological signs, excluding radiculopathy unless specific clinical signs are present. Insurers may deny claims if injuries are deemed below this threshold.
- Contributory Fault: If the injured person contributed to the accident, insurers may reduce or deny benefits. For example, a pedestrian jaywalking or a cyclist failing to use a bike lane could be seen as partially at fault.
- Lack of Evidence: Insurers require thorough documentation, including medical records, accident reports, and witness statements. Claims lacking this evidence may be rejected.
How to Challenge a Denied CTP Claim
Injured claimants should:
- Request a written explanation from the insurer detailing why the claim was denied.
- Submit additional evidence, such as medical reports from registered medical practitioners or accident scene photographs.
- Appeal through SIRA if the insurer refuses to reconsider. SIRA provides a formal process to dispute decisions, including a review by a medical assessor.
Evidence That Matters Most
Insurers typically require:
- Medical records confirming the injury and its link to the accident.
- Accident reports from police or witnesses.
- Income records to support claims for lost wages.
- Witness statements to corroborate the incident.
For example, a pedestrian injured in a car park must provide medical evidence of a spinal nerve-root injury with neurological signs. Without this, the claim may be denied under the threshold definition.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident if the injury is a 'threshold injury'. For non-threshold injuries, there is no strict time limit, but delays can complicate evidence collection. Injured people should consult a legal professional if:
- The insurer refuses to acknowledge liability.
- Medical evidence is unclear or contested.
- The claim is denied without a written explanation.
SIRA Guidance for Disputed Claims
SIRA’s Motor Accident Claims page outlines the process for disputing decisions. Claimants should refer to the 'What You Can Claim' section to understand available benefits, including weekly income payments and treatment costs. SIRA also provides templates for formal disputes and explains how to request a review of an insurer’s decision.
Next Steps for Injured Claimants
If your CTP claim has been denied, time limits and legal procedures may affect your options. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.