When an insurer denies a Compulsory Third Party (CTP) claim in New South Wales, claimants must understand their legal rights and prepare for medical assessments. This article explains how insurers may reject claims, what steps to take, and how SIRA guides the process. It also covers time limits, dispute options, and when to seek independent legal advice.
What Happens When an Insurer Denies a CTP Claim?
Under the Motor Accident Injuries Act 2017, insurers must assess claims based on the facts and applicable guidelines. A denial may occur if the insurer disputes liability, questions the injury’s severity, or claims the injury falls outside the threshold for benefits. For example, if a claimant’s injuries are deemed ‘threshold injuries’ (such as soft tissue damage), the insurer may argue that benefits should not continue beyond 52 weeks.
Insurers must provide a written explanation for denials, referencing the Motor Accident Guidelines. If a claimant disagrees, they may request a review or escalate the matter to SIRA. However, claimants should note that insurers are not required to accept all claims, and disputes often hinge on medical evidence.
Preparing for Medical Assessments
Medical assessments are critical in determining the nature and severity of injuries. Claimants should:
- Gather all medical records from doctors, physiotherapists, and specialists involved in their care.
- Document symptoms and treatment progress in a journal, as this can support claims of ongoing impairment.
- Understand the purpose of the assessment: insurers may use it to determine if injuries meet the threshold for benefits or if the claimant is eligible for long-term payments.
- Seek independent medical opinions if they believe the assessment is biased or incomplete.
SIRA provides guidelines on what constitutes a ‘threshold injury’ and how to assess long-term impairment. Claimants should familiarise themselves with these to challenge decisions they believe are unfair.
SIRA’s Role in Denied Claims
SIRA oversees the CTP scheme and provides authoritative guidance on claim assessments. If an insurer denies a claim, claimants can request a review by SIRA, which may involve a medical expert assessing the injury. SIRA’s guidelines clarify that:
- Threshold injuries are limited to soft tissue damage without significant functional impairment.
- Long-term benefits require evidence of ongoing impairment affecting daily activities.
- Medical assessments must be conducted by registered practitioners and follow SIRA’s protocols.
Claimants should note that SIRA’s decisions are not binding unless the insurer has accepted the guidelines. If a claimant believes an assessment is flawed, they may need to seek independent expert input.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident, but this does not apply to all benefits. For example, weekly income payments and treatment benefits are limited to 52 weeks unless the injury meets the threshold for long-term impairment. If an insurer denies a claim after this period, claimants may need to re-establish their case through new evidence.
Disputes can also arise if an insurer refuses to cover a claimant’s legal costs. Under the NSW Civil and Administrative Tribunal (NCAT) rules, claimants may apply for a review of the insurer’s decision, though this process can be complex.
When to Seek Legal Advice
Claimants should consult a solicitor if:
- The insurer’s denial lacks clear legal reasoning.
- Medical assessments are delayed or refused.
- The claimant is unsure how to challenge a decision.
- They need help navigating SIRA’s review process.
Legal professionals can help claimants understand their rights, challenge unfair denials, and ensure they meet all procedural requirements. It is important to act promptly, as time limits may affect the ability to dispute decisions.
Next Steps
If you are facing a denied CTP claim in NSW, it is crucial to prepare for medical assessments and understand your legal options. General information cannot determine whether a claim is available in an individual case. Time limits and procedural requirements may apply. To request contact about your circumstances, complete the quick, no obligation enquiry form.