If your CTP claim is denied by an insurer in Western NSW, understanding your rights and next steps is critical. Under the Motor Accident Injuries Act 2017 (MAIA), insurers must provide a written explanation for claim rejections. This article explains what the Personal Injury Commission (PIC) expects in disputes, how SIRA guides resolution, and practical steps to challenge a denial.
Legal Framework for CTP Claim Denials
The MAIA governs CTP claims in NSW, requiring insurers to pay benefits for injuries caused by motor vehicles. Section 4.4 of the Act limits weekly payments and treatment benefits after 52 weeks if only threshold injuries are involved. SIRA’s What you can claim page confirms insurers must cover eligible injuries, including soft tissue injuries meeting spinal nerve-root criteria.
Insurers cannot unilaterally deny claims without justification. If a claim is rejected, the PIC expects the insurer to provide a detailed written response outlining the reason, such as failure to meet injury thresholds or incomplete documentation. Denials must align with SIRA’s Motor Accident Claims guidelines, which clarify what constitutes a valid claim.
Practical Steps for Claimants in Disputes
When an insurer denies a claim, the PIC expects claimants to:
- Request a written explanation within 28 days of the denial, as per SIRA’s dispute resolution protocols.
- Gather medical evidence showing the injury meets threshold criteria, including clinical notes and imaging reports.
- Submit a formal dispute via SIRA’s online portal or by letter, referencing the insurer’s refusal to pay.
SIRA’s Making a motor accident claim page advises claimants to include all relevant documents, such as accident reports, witness statements, and income records, to support their case. If the insurer disputes the injury’s severity, the PIC expects claimants to seek a second medical opinion to challenge the assessment.
SIRA’s Role in Resolving Disputes
SIRA oversees CTP claims and provides a structured process for resolving disputes. If an insurer denies a claim, the PIC expects claimants to:
- Submit a dispute to SIRA within 28 days of the denial.
- Wait for the insurer’s response to the dispute, which must include a revised decision.
- Appeal to the Personal Injury Commission if the insurer refuses to pay, following the Internal Review process outlined in SIRA’s guidelines.
SIRA’s What you can claim page confirms that disputes must be resolved within 28 days of submission. If the insurer fails to comply, the PIC expects claimants to escalate the matter to the NSW Civil and Administrative Tribunal (NCAT) for further review.
Time Limits and When to Seek Advice
CTP claimants must act quickly. Under the MAIA, insurers have 28 days to respond to a dispute, and claimants have 52 weeks to claim weekly benefits for threshold injuries. If an insurer denies a claim beyond these deadlines, the PIC expects claimants to:
- File a complaint with SIRA within 28 days of the denial.
- Seek legal advice if the insurer refuses to pay after multiple attempts to resolve the dispute.
The PIC also expects claimants to understand that disputes are not guaranteed to succeed. SIRA’s guidelines state that challenges to injury assessments must be supported by new evidence, such as a revised medical report. Claimants should avoid disputing decisions without a clear legal basis, as this may delay resolution.
Example Scenario
A cyclist in Western Sydney claims weekly benefits for a soft tissue injury but is denied by the insurer. The PIC expects the claimant to:
- Request a written explanation of the denial.
- Submit a dispute to SIRA, attaching medical evidence of the injury.
- Await the insurer’s response and escalate to NCAT if the claim is rejected.
This example illustrates the PIC’s expectation that claimants follow SIRA’s process and provide sufficient evidence to support their case.
Next Steps
CTP claim denials can be complex, but the PIC expects claimants to act decisively. If your claim is denied, contact SIRA to understand your options and consider seeking legal advice if the insurer refuses to pay. Time limits apply, so act promptly to protect your rights.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.