What SIRA (PIC) Expect in Denied CTP Claims
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 your CTP claim is denied by an insurer in rural or remote NSW, the Personal Injury Commission (PIC), managed by SIRA, has specific expectations for resolving disputes. This guide explains what evidence and processes matter, how SIRA handles rural challenges, and steps to take when a claim is denied.
NSW CTP Rules Behind Claim Denials
CTP claims in NSW are governed by the Motor Accident Injuries Act 2017 and SIRA’s guidelines. Insurers must pay benefits if a claim meets the legal criteria, such as injuries resulting from a motor vehicle accident. However, insurers may deny claims if they dispute:
- The injury’s classification (e.g., threshold injury vs. whole-person impairment)
- The claimant’s entitlement to benefits
- The link between the accident and the injury
SIRA’s role is to resolve disputes where insurers fail to comply with the law. In rural areas, limited access to legal resources or medical records may affect how disputes are handled.
Evidence SIRA Requires for Denied Claims
SIRA expects claimants to provide clear evidence to support their claim. Key documents include:
- Medical records confirming the injury (e.g., scans, specialist reports)
- Accident reports from police or witnesses
- Proof of income to support weekly benefits claims
- Evidence of the accident’s location and circumstances (e.g., photographs, witness statements)
In rural areas, claimants may need to rely on alternative evidence if physical records are unavailable. For example, a doctor’s note confirming an injury after a car accident in a remote car park may be sufficient if other records are lost.
How SIRA Handles Disputes in Rural Areas
SIRA’s dispute resolution process is designed to be accessible, even in remote locations. Key considerations include:
- Internal reviews: Insurers must first address disputes internally before escalating to SIRA. This includes reviewing medical evidence and assessing whether the claim meets the threshold injury criteria.
- Medical assessments: If a dispute involves injury severity, SIRA may require an independent medical opinion. Rural claimants should seek assessments from approved medical practitioners, even if travel is required.
- Time limits: Claimants must notify SIRA of a dispute within 28 days of the insurer’s decision. Delays may affect eligibility for benefits.
Steps to Take if Your Claim is Denied
If your insurer denies your claim, follow these steps:
- Request a written explanation of the denial, including the specific reasons.
- Gather additional evidence to challenge the denial, such as a second medical opinion or witness statements.
- Submit a dispute to SIRA within 28 days. Use the online portal or contact SIRA directly.
- Seek legal advice if the dispute escalates. Rural claimants may need to use legal aid services or community legal centers.
Example: Dispute in a Remote Car Park
Consider a claimant injured in a car park in a remote area. The insurer denies the claim, arguing the injury is a minor soft-tissue injury. SIRA would expect the claimant to provide:
- A medical report confirming a spinal nerve-root injury (as per the Motor Accident Guidelines)
- Evidence the accident occurred in a car park (e.g., CCTV footage, witness account)
- Proof of income to support weekly benefits
If the claimant can demonstrate the injury meets the threshold injury criteria, SIRA is more likely to uphold the claim.
When to Seek Advice
Disputes can be complex, especially in rural areas with limited legal resources. Seek advice if:
- The insurer’s denial is unclear or inconsistent with the law
- You need help gathering evidence
- You face delays in accessing medical assessments
Legal professionals in rural NSW can assist with dispute resolution, internal reviews, and appeals. However, note that a challenge does not guarantee a changed decision, SIRA will assess the claim based on the evidence.
Next Steps
CTP claim denials in rural NSW require careful attention to evidence and deadlines. SIRA’s processes are designed to be accessible, but claimants must act promptly and provide clear documentation. If you’re unsure how to proceed, complete the quick, no obligation enquiry form to request contact about your circumstances.