Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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 disputes your ability to return to daily activities after a motor accident on the Central Coast, understanding NSW CTP rules and internal review processes is critical. This article explains how insurers assess functional capacity claims, the SIRA guidelines governing disputes, and practical steps to challenge a decision before escalating to the Personal Injury Commission (PIC) or SIRA.
How NSW CTP Insurers Handle Internal Reviews
NSW CTP insurers must assess claims under the Motor Accident Injuries Act 2017 and SIRA guidelines. When a claimant disputes their ability to return to daily activities, insurers typically conduct an internal review to evaluate medical evidence, functional capacity assessments, and daily activity logs. This process involves re-examining the claimant’s medical records, rehabilitation progress, and whether they meet the 'returning to daily activities' threshold outlined in SIRA’s Motor Accident Guidelines.
Insurers may also consider whether the claimant’s injuries align with the 'threshold injury' definition under the Act. For example, if a claimant’s injuries are classified as a soft-tissue injury (e.g., whiplash) but they cannot perform routine tasks like cooking or shopping, the insurer must determine if this functional limitation qualifies for additional benefits beyond the 52-week statutory period. SIRA’s guidelines clarify that such limitations must be supported by clinical evidence, including neurological signs or radiculopathy as defined in the Motor Accident Guidelines.
Practical Steps and Evidence for Disputes
If your insurer disputes your functional capacity, gather the following evidence:
- Medical records: Highlight any documentation showing ongoing limitations, such as a physiotherapist’s report or a doctor’s note.
- Functional capacity assessment (FCA): Ensure the assessment includes specific details about daily activities (e.g., lifting, walking, cognitive tasks) and how your injuries prevent you from performing them.
- Daily activity logs: Track your ability to perform routine tasks, such as cooking, shopping, or managing household chores.
- Witness statements: Include testimony from family members or employers about your functional limitations.
- Insurer correspondence: Document all communications with the insurer, including dates and details of any disputes.
A practical example: Sarah, a Central Coast resident, was denied additional benefits after a car accident because her insurer claimed she could return to daily activities. Sarah submitted a revised FCA showing she could not lift heavy objects for 12 weeks due to a spinal nerve-root injury, as outlined in SIRA’s guidelines. The insurer re-reviewed the claim and adjusted the benefits.
Time Limits, Disputes and When to Seek Advice
Insurers must act within 52 weeks of the accident for statutory benefits, but disputes over functional capacity can extend beyond this period. If your insurer refuses to reconsider their decision, you may escalate the matter to the PIC or SIRA. However, internal reviews are typically the first step before involving these bodies.
Key considerations:
- Escalation timelines: You must request an internal review within a reasonable time (usually 28 days of receiving the decision letter).
- SIRA’s role: If the insurer refuses to review or disputes the claim, SIRA may intervene to mediate or make a binding decision.
- Legal advice: If the insurer’s review is unsatisfactory, consult a solicitor to explore options like disputing the functional capacity assessment or seeking compensation for additional losses.
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