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 is denied, insurers must follow strict legal rules under NSW law. This article explains what claimants can expect from PICs during disputes, including insurer obligations, dispute resolution steps, and SIRA's role in Albury. Time limits, evidence requirements, and practical actions are outlined to help injured people understand their rights.
Legal Obligations of Insurers When Denying a CTP Claim
Under the Motor Accident Injuries Act 2017, insurers must provide clear reasons for denying a claim. Section 4.4 of the Act specifies that benefits are limited to injuries meeting the 'threshold injury' definition, which includes soft tissue injuries with neurological signs. Insurers cannot unreasonably withhold benefits and must offer an internal review before disputing a claim.
SIRA guidelines (https://www.sira.nsw.gov.au/claims/motor-accidents) state insurers must:
- Acknowledge claims within 10 business days
- Provide written reasons for denial
- Allow claimants to submit additional evidence
- Comply with the 52-week statutory benefit limit for threshold injuries
Insurers must also comply with the Motor Accident Injuries Regulation 2017, which outlines procedures for assessing injuries and determining entitlements. Failure to follow these rules may result in claims being re-evaluated.
Practical Steps for Claimants in Disputes
When a claim is denied, claimants should:
- Request an internal review in writing, referencing the insurer's own guidelines. SIRA advises claimants to include medical records, accident reports, and witness statements.
- Submit evidence of injuries meeting the threshold definition. For example, a pedestrian denied benefits for a soft tissue injury should provide medical imaging showing spinal nerve-root damage with neurological signs.
- Use SIRA's dispute resolution pathway if the insurer refuses to reconsider. The Personal Injury Commission (PIC) can review claims where there's a disagreement about injury severity or benefits.
- Seek independent medical opinions if the insurer disputes the injury's nature. SIRA recommends obtaining reports from registered medical practitioners who can assess whether the injury meets the 'threshold injury' criteria.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident for statutory benefits. However, disputes about injury severity or benefits can extend beyond this period. If a claim is denied after 52 weeks, claimants may need to:
- Appeal to the NSW Civil and Administrative Tribunal (NCAT)
- Request a review by the PIC
- Seek legal advice if the insurer refuses to engage
SIRA's dispute resolution process (https://www.sira.nsw.gov.au/claims/motor-accidents/making-a-claim) allows claimants to challenge decisions by submitting a formal objection. This process is distinct from legal action and is designed to resolve disputes without court involvement.
Example: Disputing a Denied Claim for Soft Tissue Injury
Consider a cyclist in Albury who suffered a soft tissue injury with spinal nerve-root damage. The insurer denies benefits, claiming the injury does not meet the threshold definition. The claimant can challenge this by:
- Submitting MRI scans showing neurological signs
- Providing a medical report from a registered practitioner
- Requesting an internal review under the insurer's own guidelines
If the insurer still refuses to pay, the claimant can escalate the matter to SIRA for further review.
When to Seek Legal Advice
Claimants should consult a solicitor if:
- The insurer refuses to provide written reasons for denial
- The claim is denied after 52 weeks
- The dispute involves complex injuries like whole person impairment
- The insurer threatens to terminate the claim
Legal professionals can help claimants understand their rights under the Motor Accident Injuries Act 2017 and ensure insurers comply with their obligations.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.