Insurer Denial of CTP Claim: What You Can Expect in NSW
If your CTP insurer in Greater Sydney denies your claim for compensation, you are not without recourse. The Motor Accident Injuries Act 2017 (MAIA) and the Motor Accident Injuries Regulation 2017 establish a clear process for disputing a denial. The insurer must provide a written reason for the decision, and you have the right to request an internal review. The Personal Injury Commission (PIC) oversees dispute resolution, and its expectations are based on statutory obligations and SIRA’s guidance. You can expect a structured process involving evidence submission, medical assessment and formal review, but there is no guarantee the decision will be overturned.
The Legal Framework for Disputes in NSW
All CTP claims in NSW are governed by the Motor Accident Injuries Act 2017, which replaced the Motor Accidents Compensation Act 1999 for accidents occurring on or after 1 December 2017. This law sets out the rights and obligations for claimants and insurers. When an insurer denies a claim, the decision must be based on the law and evidence, not on policy interpretation alone. The insurer must notify you in writing of the denial and the grounds, including any assessment of fault, injury threshold, or eligibility for benefits.
The PIC has a role in reviewing decisions, particularly where a claimant disputes the insurer’s assessment of injury, fault, or entitlement to benefits. Under the MAIA, you may request an internal review from the insurer within 28 days of receiving the denial. If the internal review does not resolve the dispute, you may apply to the PIC for a determination. The PIC’s role is to assess whether the insurer’s decision was reasonable and supported by evidence.
Practical Steps and Evidence That Matter
When an insurer denies your claim, the most critical step is to preserve all documentation. This includes:
- A copy of the insurer’s written denial letter
- All medical records related to the accident and injury
- Photographs of the accident scene, vehicle damage, and visible injuries
- Witness statements or contact details
- Records of lost income, if applicable
- Correspondence with the insurer, including emails and letters
The PIC expects claimants to provide a complete record of the injury and its impact. Medical evidence is particularly important. The PIC will assess whether the injury meets the threshold for damages under the Motor Accident Injuries Act 2017, which requires a permanent impairment of at least 10% of the whole person. For claims involving soft tissue injuries, the PIC will apply the Motor Accident Guidelines, which define when a spinal nerve-root injury constitutes a threshold injury.
If the insurer denies benefits due to a claimant’s contributory fault, you may still be entitled to treatment and care benefits and weekly income payments, depending on the extent of your contribution to the accident. The PIC will assess whether the claimant’s actions were a substantial factor in causing the accident, and whether a reduction in benefits is appropriate.
Internal Review and PIC Dispute Pathways
After receiving a denial, you must request an internal review from the insurer within 28 days. The insurer must complete the review within 28 days of receiving your request. If the insurer upholds the original decision, you may then apply to the PIC for a determination. The PIC will not automatically accept your case, your application must demonstrate that the insurer’s decision was not reasonable or was not supported by the evidence.
For medical disputes, the PIC may require a second medical assessment. You have the right to request an independent medical assessment (IMA) if you believe the insurer’s medical report is inaccurate or incomplete. The PIC will consider the IMA and may order a review of the original assessment.
The PIC’s process is not a new claim. It is a review of the insurer’s decision. You cannot introduce new facts or evidence unless they were not available during the initial claim process. The PIC will not reinvestigate the accident unless new evidence emerges that was not reasonably accessible at the time.
Time Limits and the Importance of Acting Promptly
Time limits apply to dispute processes. You must request an internal review within 28 days of receiving the denial. If you fail to do so, you may lose the right to challenge the decision through the PIC. The PIC’s time limit for making a determination is 90 days from the date of application, but this may be extended if additional evidence is required.
If you are seeking damages, you must file a claim in the District Court within three years of the accident date. This deadline is strict and cannot be extended unless a court grants leave.
Hypothetical Example: Dispute Over a Soft Tissue Injury
A pedestrian in Sydney was struck by a car in a car park in June 2024. The insurer denied treatment and care benefits, stating that the injury was not a threshold injury. The claimant submitted medical records showing a diagnosis of a cervical spine injury with neurological signs, but no radiculopathy. The insurer argued that the injury did not meet the threshold under the Motor Accident Guidelines.
The claimant requested an internal review and submitted an IMA report from a specialist neurologist confirming a spinal nerve-root injury with sensory disturbance. The PIC reviewed the evidence and found that the injury met the threshold definition under the Guidelines, as it involved neurological signs other than radiculopathy. The PIC ordered the insurer to pay treatment and care benefits and to reconsider eligibility for damages.
When to Seek Independent Advice
A denial does not mean your claim is hopeless. However, the process is complex and evidence-heavy. The PIC expects claimants to act promptly, provide complete documentation, and understand the legal thresholds. If you are unsure about the insurer’s grounds for denial, or if the dispute involves medical assessment, legal interpretation, or fault allocation, it is advisable to seek independent advice before proceeding.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.