How NSW CTP Insurers Assess Return to Daily Activities During Internal Reviews
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 NSW CTP insurer is disputing your ability to return to daily activities, understanding their internal review process is critical. Insurers assess functional capacity based on medical evidence, claimant reports, and SIRA guidelines. This article explains how insurers evaluate return-to-activities claims, what evidence matters, and when to seek legal advice.
The NSW CTP Internal Review Process
Under the Motor Accident Injuries Act 2017, insurers must review claims where a claimant disputes the adequacy of benefits or the insurer’s assessment of injury severity. During internal reviews, insurers evaluate whether claimants can perform daily activities like cooking, shopping, or managing personal care. This assessment is based on:
- Medical reports from treating practitioners
- Claimant self-reports of functional limitations
- SIRA guidelines on threshold injuries and functional capacity
Insurers may request additional medical assessments or clarification from your treating doctor. If your ability to return to daily activities is contested, the insurer must provide a written explanation of their reasoning.
Evidence Required for Daily Activity Claims
To support your claim about returning to daily activities, you must provide:
- Medical evidence showing your injury’s impact on functional capacity. This includes:
- Doctor’s notes detailing your injury’s effect on daily tasks
- Rehabilitation records
- Evidence of pain or mobility issues affecting routine activities
- Accident-related evidence such as:
- Police reports or accident statements
- Witness statements about your pre-accident activities
a Claimant activity log documenting your current ability to perform daily tasks
Insurers often challenge claims by arguing that claimants have not fully returned to pre-accident activities. For example, if you can no longer cook due to hand injuries, your insurer may dispute whether this constitutes a 'threshold injury' under the Motor Accident Guidelines.
Time Limits and Dispute Options
Insurers must respond to internal review requests within 28 days under the Motor Accident Injuries Regulation 2017. If your claim is denied or the insurer refuses to reconsider, you may:
- Request a review by the Personal Injury Commission (PIC). The PIC can order an independent medical assessment if there’s a dispute about the injury’s severity.
- Appeal to SIRA. If the PIC’s decision is unsatisfactory, you may seek a review by the State Insurance Regulatory Authority.
Note: An internal review does not guarantee a changed decision. Insurers must provide clear reasoning for their assessment, but you may need legal assistance to challenge their interpretation of your medical evidence.
Practical Example: Dispute Over Returning to Work
Consider a claimant who was a nurse and now struggles to lift patients due to back injuries. The insurer disputes whether this injury meets the 'threshold injury' definition under the Motor Accident Guidelines. The claimant must provide:
- A medical report confirming the injury’s impact on lifting capacity
- Evidence of pre-accident work duties
- A statement from their employer about their ability to return to work
In this case, the insurer may argue the injury does not meet the threshold for weekly income payments, requiring a detailed analysis of the Motor Accident Injuries Act 2017 s 4.4.
When to Seek Legal Advice
If your insurer’s internal review denies your claim or disputes your ability to return to daily activities, consider seeking legal advice. A solicitor can:
- Challenge the insurer’s interpretation of your medical evidence
- Request a PIC review or SIRA intervention
- Help you navigate the 28-day internal review timeline
Remember: Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.
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