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).
If your CTP claim has been denied by an insurer, you are not alone. Insurers often deny claims by disputing the nature of the injury, the medical evidence, or the eligibility for benefits. This article explains how NSW CTP insurers typically deny claims, what steps to take when a claim is denied, and how to use SIRA’s guidelines to challenge denials on the Central Coast. It also outlines the role of medical assessments in CTP claims and how to prepare for them effectively.
How NSW CTP Insurers Typically Deny Claims
Insurers may deny claims by arguing that the injury does not meet the definition of a 'threshold injury' under the Motor Accident Injuries Act 2017. A threshold injury is defined as an injury that results in a whole person impairment of 10% or more, or a soft tissue injury with neurological signs. If the injury falls below this threshold, insurers may argue that benefits are not payable. For example, an insurer might deny a claim for a whiplash injury if the medical evidence does not show a whole person impairment of 10% or more.
Insurers may also deny claims by disputing the medical evidence. They may request additional assessments or challenge the credibility of the treating medical practitioner. In some cases, insurers may argue that the claimant has not followed the recommended treatment plan or has not attended all scheduled appointments. The CTP scheme is designed to cover injuries regardless of who was at fault.
Steps to Take When Your CTP Claim Is Denied
If your claim has been denied, the first step is to understand the reason for the denial. Review the insurer’s letter carefully and note any specific concerns they have raised. If the denial is based on the medical evidence, you may need to seek a second opinion from another medical practitioner. SIRA’s guidelines provide detailed information on what constitutes a threshold injury and how to assess the medical evidence. You can refer to SIRA’s website for more information on what you can claim under the CTP scheme.
It is also important to ensure that all medical records are complete and up to date. If the insurer has requested additional assessments, you should comply with their request. However, you should also ensure that the assessments are conducted by a medical practitioner who is familiar with the CTP scheme and the specific requirements for benefits. If you are unsure about the process, you may want to seek advice from a solicitor who specialises in CTP claims.
Using SIRA’s Guidelines to Challenge Denied Claims
SIRA’s guidelines are an essential resource for claimants facing denied CTP claims. The guidelines provide detailed information on how to assess injuries, what constitutes a threshold injury, and how to prepare for medical assessments. If your claim has been denied, you should review the guidelines to understand the basis of the denial and how to challenge it. For example, if the insurer has denied your claim based on the medical evidence, you may need to provide additional evidence to support your case. This could include medical records, witness statements, and a detailed explanation of how the injury has affected your daily life.
SIRA also provides information on how to challenge a denied claim. If you are not satisfied with the insurer’s decision, you may need to request a review of the claim. The insurer must provide a written explanation of their decision and may offer an opportunity for you to submit additional evidence. If the insurer still denies the claim, you may need to seek legal advice to explore further options.
Preparing for Medical Assessments
Medical assessments are a key part of the CTP claims process. If your claim has been denied, the insurer may request an independent medical assessment to determine whether you are eligible for benefits. It is important to prepare for these assessments by ensuring that all medical records are complete and up to date. You should also ensure that you understand the purpose of the assessment and what evidence is required. If you are unsure about the process, you may want to seek advice from a solicitor who specialises in CTP claims.
During the assessment, the medical practitioner will evaluate your injury and determine whether it meets the definition of a threshold injury. If the injury does not meet the threshold, the insurer may still offer benefits for the injury, depending on the specific circumstances. Therefore, even if the injury does not meet the threshold, you may still be eligible for benefits.
Time Limits and When to Seek Advice
There are time limits for making a CTP claim. If your claim has been denied, you should act quickly to challenge the denial. The time limit for making a claim is generally 52 weeks from the date of the accident. However, if your claim has been denied, you may have additional time to challenge the denial. It is important to seek advice as soon as possible to ensure that you do not miss any deadlines.
If you are unsure about the process or need help challenging a denied claim, you should seek advice from a solicitor who specialises in CTP claims. A solicitor can help you understand the basis of the denial, prepare for medical assessments, and challenge the insurer’s decision. Therefore, even if the injury does not meet the threshold, you may still be eligible for benefits.
Next Steps
If your CTP claim has been denied, you should take the following steps: Review the insurer’s letter carefully, seek a second opinion from another medical practitioner, and ensure that all medical records are complete and up to date. If you are unsure about the process, you should seek advice from a solicitor who specialises in CTP claims. The CTP scheme is designed to cover injuries regardless of who was at fault. Therefore, even if the injury does not meet the threshold, you may still be eligible for benefits.
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