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 insurer in Auburn NSW has refused to approve your claim for returning to daily activities under the NSW Compulsory Third Party (CTP) scheme, you may need to challenge their decision. This article explains how to dispute an insurer's internal review of your ability to perform daily tasks, the legal basis for such disputes, and when to seek further assistance. The NSW Motor Accident Injuries Act 2017 and SIRA guidelines govern these claims, and understanding the process is critical to protecting your entitlements.
The Legal Framework for Daily Activity Claims
Under the Motor Accident Injuries Act 2017, insurers must assess claims based on medical evidence and the claimant's ability to perform daily activities. SIRA (State Insurance Regulatory Authority) oversees the CTP scheme and ensures insurers comply with statutory obligations. If an insurer denies a claim for daily activities, they must provide a written explanation detailing their reasoning. This includes whether the claimant meets the 'threshold injury' criteria or has sustained a 'whole person impairment' that affects their capacity for routine tasks.
Practical Steps to Challenge an Insurer's Decision
- Review the insurer's written response to understand their specific concerns. Insurers often cite medical reports or clinical assessments as justification for denying claims.
- Gather evidence to challenge their assessment. This includes:
- Medical records confirming your ability to perform daily activities.
- Activity logs or witness statements detailing your current routine.
- Correspondence with the insurer showing inconsistencies in their evaluation.
- Request an internal review within 28 days of receiving the initial decision. Insurers must provide a written response within 21 days of this request.
- Contact SIRA if the insurer refuses to reconsider their decision. SIRA has the authority to mediate disputes and ensure compliance with the Motor Accident Injuries Act 2017.
Time Limits and Dispute Options
Insurers must respond to claims within specific timeframes. For example, weekly benefits must be paid within 14 days of a claim being accepted. If an insurer fails to act within these limits, it may weaken their position in a dispute. Claimants should also be aware that the 52-week statutory benefit period applies to 'threshold injuries', if your injury falls within this category, benefits may be limited after 52 weeks. However, this does not apply to claims involving 'whole person impairment' or long-term care needs.
When to Seek Independent Advice
If your insurer's decision appears unfair or based on incomplete evidence, you may need to consult a solicitor. Legal professionals can help you:
- Challenge the insurer's interpretation of medical evidence.
- File a formal dispute with SIRA or the Personal Injury Commission (PIC).
- Explore options for escalating the matter to the NSW Civil and Administrative Tribunal (NCAT) if necessary.
Example Scenario
Consider a claimant in Auburn who was denied a claim for returning to work due to a 'threshold injury' assessment. The insurer cited a medical report indicating limited mobility. However, the claimant's activity log showed they could perform light household tasks. By providing this evidence to SIRA, the claimant could challenge the insurer's decision and demonstrate that their daily activities were not restricted as claimed.
Next Steps
If you disagree with your insurer's assessment of your ability to return to daily activities, act promptly. Review the insurer's decision, gather supporting evidence, and contact SIRA to escalate the matter. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.