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).
Insurers in NSW may deny CTP claims based on specific legal and medical criteria. If your claim was rejected, understanding the insurer’s reasoning and how to challenge it is critical. This guide explains the factors insurers consider, how SIRA guidelines apply, and practical steps to contest decisions in rural areas like the Blue Mountains and Nepean.
Why Insurers Deny CTP Claims
Insurers evaluate claims under the Motor Accident Injuries Act 2017 and SIRA guidelines. Common reasons for denial include:
- Threshold injuries: Claims for soft tissue injuries (e.g., whiplash) may be limited to statutory benefits after 52 weeks, as outlined in s 4.4 of the Act.
- Contributory fault: If the claimant is partly at fault, insurers may reduce or deny benefits.
- Medical evidence gaps: Insurers may dispute claims if medical records lack specific clinical signs, such as radiculopathy (as defined in the Motor Accident Guidelines).
- Eligibility issues: Claims for injuries not covered by the CTP scheme (e.g., pre-existing conditions) may be rejected.
Using SIRA Guidelines to Challenge Decisions
SIRA’s Motor Accident Claims page outlines how insurers assess claims. To challenge a denial:
- Review the insurer’s decision letter: Insurers must provide reasons for denial, including references to specific sections of the Motor Accident Injuries Act or guidelines.
- Gather supporting evidence: Medical records must clearly show injuries matching SIRA’s threshold criteria. For example, a spinal nerve-root injury with neurological signs (not just radiculopathy) may qualify for statutory benefits.
- Request an internal review: Insurers must allow claimants to appeal decisions within 28 days of receiving the letter (per SIRA’s Making a Motor Accident Claim guidelines).
Common Denial Reasons in Rural NSW
Rural areas like the Blue Mountains and Nepean may face unique challenges, such as:
- Limited access to specialists: Insurers may dispute claims if medical evidence is from a non-SIRA-registered practitioner.
- Accident location ambiguity: Claims involving private property or car parks require detailed evidence to establish the accident’s legal character.
- Delayed reporting: Insurers may deny claims if the claimant does not notify them within 52 weeks of the accident (per s 3.28 of the Act).
How to Contest a Denial
If your claim is denied, follow these steps:
- Submit a formal dispute: Use SIRA’s dispute resolution process, which includes an internal review and, if needed, a review by the Personal Injury Commission.
- Seek independent medical evidence: A second opinion from a SIRA-registered medical practitioner may be required to challenge the insurer’s assessment.
- Consider legal advice: While not mandatory, a solicitor can help navigate complex disputes, especially if the insurer refuses to engage with SIRA guidelines.
Time Limits and Next Steps
CTP claims must be submitted within 52 weeks of the accident. If denied, you have 28 days to request an internal review. If the insurer refuses to reconsider, you may apply to the Personal Injury Commission for a review. Note that challenges do not guarantee a changed decision, insurers must still meet the legal threshold.
When to Seek Help
If you’re unsure whether your claim meets SIRA’s criteria, or if the insurer’s decision appears unfair, contact a legal professional. General information cannot determine whether a claim is available in your case. Time limits and procedural requirements may apply. To request contact about your circumstances, complete the quick, no obligation enquiry form.