Why Insurers Deny CTP Claims in NSW
Insurers often deny claims by disputing the injury's severity, claiming the accident wasn't a motor vehicle incident, or arguing the claimant isn't eligible. Common reasons include:
- Injury doesn't meet the 'threshold injury' definition under the Motor Accident Injuries Act 2017
- Lack of medical evidence confirming the injury
- Dispute over the accident's cause or location
- Claimant's pre-existing conditions affecting eligibility
For example, an insurer might deny a claim for a soft tissue injury (like a whiplash) if they argue it doesn't meet the spinal nerve-root criteria in the Motor Accident Guidelines.
How to Challenge an Unfair Denial
- Review SIRA's Dispute Process
SIRA provides a formal process to challenge denied claims. You can request a review of the insurer's decision by submitting new evidence or disputing their interpretation of the law.
- Gather Medical Evidence
Insurers often require detailed medical records. Ensure your treating doctor documents:
- Specific symptoms
- Diagnostic test results
- Treatment plans
- How the injury affects daily activities
- Submit a Written Dispute
Write to the insurer explaining why you believe the denial is incorrect. Reference the Motor Accident Injuries Act 2017 and SIRA's guidelines to support your case.
What SIRA Guidance Says About Denials
SIRA's website states: 'If you disagree with a decision, you can request a review. SIRA will consider new evidence and may change its decision.' They also advise claimants to:
- Keep all correspondence with insurers
- Seek independent medical opinions if needed
- Understand the 52-week limit for weekly benefits if only threshold injuries are involved
Practical Steps to Take Now
- Document everything: Keep copies of medical records, accident reports, and insurer communications.
- Photograph the accident scene (if safe to do so) to support your account.
- Notify the insurer in writing of your disagreement, referencing specific sections of the Motor Accident Injuries Act.
- Seek independent advice if the insurer refuses to provide a written explanation for their denial.
When to Seek Legal Help
Contact a solicitor if:
- The insurer refuses to provide a written reason for the denial
- You receive a 'no liability' response despite meeting the CTP criteria
- You need help navigating SIRA's dispute process
- You're unsure whether your injury qualifies as a threshold injury
Time Limits and Next Steps
You have 52 weeks from the accident date to claim weekly benefits for threshold injuries. For non-threshold injuries, there's no time limit, but insurers may still deny claims based on lack of evidence. If your claim is denied, you can request a review at any time, though delays may affect your ability to challenge decisions.
Final Advice
CTP claims can be complex, especially when insurers deny them. Always keep detailed records and seek clarification from SIRA or a legal professional. Remember, every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.