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).
When a CTP claim is denied in Ashfield, insurers evaluate liability based on legal rules and evidence. This article explains how insurers determine fault, apply SIRA guidelines, and assess claim validity. Understanding these factors helps claimants challenge denials effectively.
How Insurers Determine Fault in CTP Claims
Insurers assess liability by determining if the accident falls under the CTP scheme. Key factors include:
- Fault attribution: Insurers must establish who caused the accident. For example, if a driver ran a stop sign, their fault would trigger liability. SIRA’s guidelines clarify that blameless accidents (where no fault is attributable) are not covered.
- Evidence review: Police reports, witness statements, and accident scene photos are critical. Insurers may dispute claims if evidence is incomplete or inconsistent.
- Vehicle use: The Motor Accident Injuries Act 2017 specifies that CTP covers injuries from motor vehicles, including cars, motorcycles, and bicycles. Claims involving pedestrians or cyclists must prove the vehicle was involved in the incident.
SIRA’s Role in Liability Assessments
SIRA’s Motor Accident Guidelines shape how insurers evaluate claims. For instance:
- Threshold injuries: Under the guidelines, injuries like whiplash or soft tissue damage may qualify if they meet specific clinical criteria. Insurers must assess whether the injury meets the spinal nerve-root definition in the guidelines.
- 52-week limit: If a claimant’s only injuries are threshold injuries, benefits are generally limited to 52 weeks. Insurers may deny claims beyond this period unless the injury meets higher impairment thresholds.
- Documentation: SIRA requires claimants to provide medical records and evidence of injury onset. Missing documentation can lead to claim denial.
Steps to Challenge a Denied CTP Claim
If an insurer denies liability, claimants can:
- Request a review: Submit additional evidence, such as a second medical opinion or updated accident reports, to dispute the denial.
- Dispute through SIRA: Claimants can apply for a review by SIRA’s Motor Accident Claims Unit. This process allows for reassessment of liability and claim validity.
- Seek legal advice: A solicitor can help challenge the denial by interpreting SIRA guidelines and identifying legal errors in the insurer’s assessment.
Example: Soft Tissue Injury and Liability
Consider a claimant in Ashfield who suffered a soft tissue injury after a car accident. The insurer may deny the claim if:
- The injury does not meet SIRA’s threshold criteria (e.g., no neurological signs),
- The claimant fails to provide medical evidence of injury onset, or
- The accident involved a non-motor vehicle (e.g., a pedestrian hit by a car without a valid CTP policy).
Next Steps After a Claim Denial
CTP claims have strict time limits. For example, claims for injuries must be made within 52 weeks of the accident, unless the injury is not discovered within that period. If a claim is denied, claimants should:
- Gather all relevant evidence,
- Submit a formal dispute to SIRA, and
- Consult a legal professional to explore options for challenging the denial.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.