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 has been denied over treatment or rehabilitation planning in Western Sydney, you're not alone. NSW insurers often reject claims by disputing the necessity of medical services, questioning the alignment of rehabilitation plans with SIRA guidelines, or challenging the evidence of injury. This article explains how to challenge such denials while ensuring your treatment and recovery plans meet legal requirements under the Motor Accident Injuries Act 2017.
How NSW CTP Insurers Typically Deny Claims
Insurers may deny claims by:
- Arguing that treatment plans lack medical necessity
- Disputing the alignment of rehabilitation goals with SIRA's 'rehabilitation planning' requirements
- Questioning the credibility of injury documentation
- Refusing to cover services not explicitly listed in the claim
For example, an insurer might deny coverage for physiotherapy sessions if the treatment plan doesn't explicitly state how the therapy addresses a 'threshold injury' under the Motor Accident Guidelines.
Evidence to Challenge an Insurer's Denial
To contest a denial, you must demonstrate:
- Medical records confirming the injury meets the 'threshold injury' definition (e.g., spinal nerve-root injury with neurological signs)
- A detailed treatment and rehabilitation plan signed by a medical practitioner
- Evidence that the plan addresses both short-term recovery and long-term functional outcomes
- Compliance with SIRA's 'rehabilitation planning' documentation standards
Insurers often require rehabilitation plans to include specific elements like:
- Expected recovery timeline
- Specific therapeutic interventions
- Alignment with the 'whole person impairment' assessment
- Evidence of how the plan prevents long-term disability
SIRA's Guidance on Denied Claims
SIRA's Motor Accident Claims page explains that insurers must approve 'treatment and care benefits' if the injury meets the threshold injury criteria. If your claim is denied, you should:
- Request a written explanation of the denial
- Submit additional evidence to support your case
- Seek a review by SIRA's Dispute Resolution Service
SIRA's 'What you can claim' page clarifies that rehabilitation planning must be 'reasonably necessary' and 'directly related to the injury'. This means insurers cannot deny coverage for services that are medically reasonable and documented in a treatment plan.
Practical Steps for Claimants in Western Sydney
- Document everything: Keep copies of all medical records, treatment plans, and correspondence with the insurer
- Consult a medical practitioner: Ensure your rehabilitation plan includes specific, measurable goals aligned with SIRA guidelines
- Request a review: If the insurer denies your claim, ask for a written explanation and submit additional evidence
- Seek independent advice: Consider consulting a solicitor specialising in CTP claims if the insurer refuses to reconsider its decision
Time Limits and Dispute Options
You have 52 weeks from the accident date to claim 'only injuries' benefits under the Motor Accident Injuries Act 2017 s 4.4. If your injury meets the 'threshold injury' criteria, you may be eligible for treatment and care benefits beyond this period. However, insurers may dispute claims after 52 weeks unless the injury involves 'whole person impairment' or long-term functional limitations.
If your claim is denied, you can:
- Submit a formal dispute to SIRA's Dispute Resolution Service
- Request a review by the NSW Civil and Administrative Tribunal (NCAT)
- Seek legal advice if the insurer refuses to reconsider its decision
When to Seek Legal Advice
Contact a solicitor if:
- The insurer refuses to provide a written explanation for its denial
- Your claim involves complex injuries like 'whole person impairment' or 'threshold injury' disputes
- You need assistance with rehabilitation planning documentation
- The insurer is disputing the necessity of specific medical services
Remember, every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.
Final Considerations
Western Sydney claimants facing denied CTP claims should focus on ensuring their treatment and rehabilitation plans meet SIRA's documentation standards. By gathering comprehensive evidence and understanding your rights under the Motor Accident Injuries Act 2017, you can challenge insurer denials effectively. Time limits and procedural requirements may apply, so acting promptly is essential.