Why Insurers Deny CTP Claims in NSW
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).
When a CTP insurer denies a claim in New South Wales, it often stems from one of several legal grounds under the Motor Accident Injuries Act 2017 (MAIA). The most common reasons include a determination that the injury was not caused by the motor accident, that the injury does not meet the threshold for damages, or that the claimant contributed to the accident through their own negligence. Insurers may also deny claims if they believe the injury was pre-existing or if the claim was not made within the required time limits. In some cases, a claim may be denied because the insurer disputes liability, particularly in incidents involving pedestrians, cyclists, or vehicles on private property. These decisions are not final and are subject to review under the SIRA framework.
How to Challenge a Denied CTP Claim
If your CTP claim has been denied, you have the right to challenge the decision through formal dispute resolution processes. The first step is to obtain a written explanation from the insurer outlining the reasons for the denial. This document is critical for any subsequent review. You may then request an internal review from the insurer, which must be completed within 28 days of your request. If the insurer upholds the denial, you can escalate the matter to the State Insurance Regulatory Authority (SIRA), which oversees dispute resolution for motor accident claims in NSW. SIRA provides a formal process for reviewing decisions, including the opportunity to submit additional evidence such as medical reports, accident scene photographs, or witness statements.
The Role of SIRA in Resolving CTP Disputes
SIRA is the independent body responsible for administering the CTP scheme in NSW and resolving disputes between claimants and insurers. When a claim is denied, SIRA can review the insurer’s decision and determine whether it was made in accordance with the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. SIRA may require the insurer to reconsider its position or issue a determination that the claim should be accepted. The process is free for claimants and can result in the reinstatement of benefits, including treatment and care benefits, weekly income payments, or damages. SIRA also provides a claims assistance service to help individuals understand their rights and prepare submissions.
Legal Protections for Injured Claimants
Under NSW law, claimants have several legal protections when facing a denied CTP claim. The MAIA ensures that insurers must assess claims in good faith and provide clear reasons for any denial. A claimant cannot be denied benefits solely because they were not at fault, as CTP insurance is no-fault in nature. However, the right to damages is subject to a threshold test: a claimant must have a permanent impairment of at least 10% to qualify for damages, unless the injury is a threshold injury as defined in the Motor Accident Injuries Regulation 2017. For threshold injuries, the insurer must still provide treatment and care benefits and weekly income payments, but damages may be restricted. If an insurer denies a claim on the basis of a pre-existing injury, they must provide medical evidence showing the injury was not caused by the accident. Injured people in Greater Sydney and across NSW are entitled to seek independent medical assessment if they believe the insurer’s assessment is inaccurate.
Evidence That Matters in a Dispute
When challenging a CTP claim denial, the strength of your evidence is critical. Key documents include medical records from the time of the accident and subsequent treatment, which should detail the nature, onset, and progression of the injury. Photographs of the accident scene, vehicle damage, or personal injuries may support your account. Witness statements, including contact details and written accounts, can help establish the circumstances of the accident. If you were employed at the time, pay slips and a letter from your employer confirming time off work due to injury can support a claim for weekly income payments. All correspondence with the insurer, including emails and letters, should be preserved. SIRA may require this evidence to be submitted in a formal dispute, so keep copies and a record of submission dates.
Time Limits and Procedural Deadlines
There are time limits that apply to challenging a CTP claim denial. While the MAIA does not impose a strict deadline for requesting a review, delays may affect the availability of evidence or the accuracy of medical assessments. It is advisable to act promptly. If you are seeking to dispute a denial through SIRA, you must do so within 12 months of the insurer’s final decision. Failure to meet this deadline may result in the claim being barred. Additionally, if you are seeking damages, you must apply to SIRA for a determination within 12 months of the date of the accident, or within 12 months of the date on which you first became aware of a permanent impairment, whichever is later. These time limits are strict and must be observed to preserve your rights.
A Realistic Example: Challenging a Denial in Sydney
Consider a cyclist in Sydney who was struck by a car at a traffic light in November 2024. The cyclist sustained a neck injury and was unable to work for six weeks. The insurer denied the claim, stating that the injury was not caused by the accident and that the medical evidence did not show a permanent impairment. The cyclist obtained a second medical opinion confirming a soft-tissue injury consistent with the accident. They submitted the report, along with photographs of the scene and a witness statement, to SIRA. SIRA reviewed the evidence and determined that the injury was caused by the accident and that the claimant met the threshold for damages. The insurer was required to reinstate weekly payments and provide treatment and care benefits. This example illustrates how evidence and formal review can lead to a successful outcome.
Next Steps After a Denial
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.