If your insurer disputes your ability to return to daily activities after a motor accident in NSW, understanding how they assess such claims is critical. Under the Motor Accident Injuries Act 2017 (MAIA), insurers must evaluate disputes using SIRA guidelines and medical evidence. This article explains how insurers review these claims, the role of SIRA, and steps to challenge a decision without guaranteeing a change.
How NSW CTP Insurers Evaluate Daily Activity Disputes
Insurers assess disputes by reviewing medical evidence, including reports from healthcare professionals, to determine if a claimant can perform daily activities. This includes tasks like cooking, shopping, or managing personal care. The insurer will typically:
- Request detailed medical records from your treating doctor
- Compare your condition to SIRA's Motor Accident Guidelines
- Consider whether your injuries meet the threshold for benefits
- Evaluate if your ability to return to activities aligns with clinical assessments
Insurers must apply the MAIA's rules about 'returning to daily activities' consistently. If they dispute your capacity, they must provide a written explanation of their reasoning.
SIRA Guidelines Shape Insurer Assessments
SIRA's Motor Accident Guidelines (2023) provide the framework for determining whether injuries qualify as 'threshold injuries' under the MAIA. For daily activity disputes, insurers must:
- Use the 'returning to daily activities' criteria in the guidelines
- Consider whether your injuries prevent you from performing routine tasks
- Assess if your condition has improved to the point of full recovery
The guidelines also outline how to evaluate 'ordinary daily activities' versus 'complex tasks' that require more specialized assessment. Insurers must apply these standards uniformly, though they may request additional medical evidence if they doubt the claimant's capacity.
Steps to Challenge an Insurer's Daily Activity Decision
If your insurer disputes your ability to return to daily activities, take these steps:
- Request a written explanation of their assessment, including which guidelines they applied
- Provide additional medical evidence showing your capacity to perform daily activities
- Seek a second opinion from a specialist familiar with SIRA's criteria
- Escalate to SIRA if the insurer refuses to reconsider, though this is a last resort
Note that insurers are not required to change their decision simply because you challenge it. The MAIA allows for disputes to be resolved through internal reviews, but there is no guarantee of a different outcome.
Time Limits and When to Seek Advice
You have 52 weeks from the accident date to claim weekly benefits for threshold injuries. After this period, insurers may stop paying benefits unless you can prove ongoing injuries. If your insurer disputes your daily activity capacity after this time, you may need to:
- Re-establish the date of your injury
- Provide fresh medical evidence of ongoing impairment
- Seek legal advice about whether your claim falls under the 'only injuries' provision of the MAIA
Disputes over daily activities often require expert legal input, especially if the insurer refuses to reconsider their decision. While SIRA can provide guidance, they do not handle individual disputes directly.
Practical Evidence to Support Your Claim
Insurers will scrutinize evidence showing your ability to perform daily activities. Key documents include:
- Detailed medical reports from your doctor
- Activity logs tracking your daily routine
- Statements from family or carers about your capacity
- Evidence of any assistive devices or adaptations you've made
You should also keep records of any conversations with your insurer, as they may request additional information during their review process.
When to Escalate to SIRA or the PIC
If your insurer refuses to reconsider their decision, you may need to escalate the matter to the Personal Injury Commission (PIC) or SIRA. However, this is not a guaranteed pathway to a changed decision. The PIC can only review claims if they believe the insurer has not followed the MAIA's rules correctly.
Remember that insurers are not required to pay benefits if they believe your injuries do not meet the threshold. If your claim is denied, you may need to seek legal advice to explore other options, such as a common law damages claim.
Final Steps for Claimants
If your insurer disputes your ability to return to daily activities, act quickly to:
- Gather all relevant medical evidence
- Request a written explanation of their assessment
- Seek legal advice if the insurer refuses to reconsider
Time limits apply to all CTP claims, so it's important to act promptly. While insurers must follow the MAIA's rules, there is no guarantee that a dispute will result in a changed decision. Always seek independent legal advice before making any decisions about your claim.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.