A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
If an insurer denies your Compulsory Third Party (CTP) claim in NSW, understanding the PIC's expectations is critical. The Personal Injury Commission (PIC) oversees disputes under the Motor Accident Injuries Act 2017, and claimants must follow specific steps to challenge a denial. This article explains what to expect, how SIRA guidelines apply, and practical actions to take when facing a denied CTP claim in Auburn.
The Legal Framework Behind CTP Claim Denials
CTP claims are governed by the Motor Accident Injuries Act 2017, which outlines the PIC’s role in resolving disputes. Insurers must provide a written explanation for denying a claim, including reasons such as lack of fault, threshold injury limits, or failure to meet statutory benefits criteria. SIRA’s guidelines clarify that insurers cannot unreasonably withhold benefits, and claimants have the right to challenge decisions through formal review processes.
Practical Steps for Claimants Facing a Denial
When an insurer denies a claim, claimants should:
- Request a written explanation of the denial, including specific reasons.
- Gather evidence such as medical records, accident reports, and witness statements.
- Submit a formal internal review request to the insurer within 28 days of the denial.
- If unresolved, escalate the matter to the PIC for further review.
SIRA’s Making a Motor Accident Claim page advises that claimants must act promptly, as time limits apply for disputing decisions. For example, weekly benefits claims must be reviewed within 52 weeks of the accident if only threshold injuries are involved.
Time Limits and the PIC’s Dispute Process
The PIC has specific timelines for resolving disputes. If an insurer denies a claim, the PIC must review it within 28 days of receiving the claimant’s request. If the claimant disputes the PIC’s decision, they can apply for a review by the NSW Civil and Administrative Tribunal (NCAT) within 28 days of the PIC’s ruling. Delays beyond these deadlines may jeopardize the claim.
What the PIC Expectsin Disputes
The PIC expects claimants to:
- Provide clear evidence supporting their claim, such as medical reports from registered practitioners.
- Adhere to procedural deadlines for internal reviews and PIC submissions.
- Avoid disputing decisions on grounds not supported by the Act, such as fault-based arguments unless the claim is for damages (not statutory benefits).
SIRA’s What You Can Claim page clarifies that the PIC will not re-examine factual disputes unless there is a clear error in the insurer’s assessment. For example, if an insurer denies weekly benefits due to a threshold injury, the PIC will not reassess the medical opinion unless new evidence is presented.
A Hypothetical Example
Consider a claimant denied weekly benefits after a car accident. The insurer argues the injuries are below the threshold. The claimant must:
- Request a written explanation of the denial.
- Submit medical records showing the injury meets the threshold (e.g., a spinal nerve-root injury with neurological signs).
- Apply for an internal review within 28 days.
- If denied, escalate to the PIC within 52 weeks of the accident.
The PIC will assess whether the insurer’s decision aligns with SIRA guidelines. If the claimant’s evidence supports a higher impairment rating, the PIC may order a reassessment.
When to Seek Legal Advice
While the PIC process is designed for self-representation, complex disputes may require legal assistance. For example, if the claim involves a medical dispute over impairment ratings or a challenge to the insurer’s interpretation of the Act, a solicitor can help navigate procedural requirements and ensure all evidence is properly submitted.
Next Steps
CTP claim disputes depend on the accident date, injury type, and evidence submitted. If you face a denied claim in Auburn, act quickly to meet deadlines and gather supporting documentation. For tailored guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.