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 you're in regional NSW and your insurer disputes whether you can return to daily activities after a motor accident, understanding the internal review process is critical. NSW CTP insurers must follow specific rules when assessing claims related to functional recovery. This article explains how insurers handle such disputes, the role of SIRA guidelines, and practical steps to challenge decisions without guaranteeing a change.
How Insurers Assess Return to Daily Activities
NSW insurers evaluate a claimant's ability to return to daily activities by reviewing medical evidence, rehabilitation progress, and functional capacity assessments. Under the Motor Accident Injuries Act 2017, insurers must base decisions on clinical guidelines, including the Motor Accident Guidelines. If an insurer disputes your ability to perform routine tasks, they may request additional medical reports or consult with a medical expert.
SIRA's Role in Dispute Resolution
SIRA (State Insurance Regulatory Authority) oversees insurer compliance with CTP rules. While SIRA does not directly intervene in internal disputes, its guidelines require insurers to provide claimants with written reasons for decisions and opportunities to respond. For example, SIRA's Making a Motor Accident Claim page states insurers must consider evidence of functional recovery before limiting benefits.
Practical Steps for Claimants
- Request Written Reasons: Insurers must provide detailed explanations for denying or limiting benefits related to daily activities. If you receive a decision, ask for the specific clinical evidence they relied on.
- Submit Additional Evidence: Provide updated medical records, activity logs, or statements from healthcare professionals to challenge the insurer's assessment. For instance, a physiotherapist's report on your ability to walk for 30 minutes could counter an insurer's claim of limited mobility.
- Seek Independent Medical Advice: If the insurer disputes your capacity to work or perform household tasks, consult a specialist familiar with CTP claims. SIRA's What You Can Claim page notes that medical evidence must directly relate to the injury's impact on daily functioning.
Time Limits and When to Seek Advice
Insurers typically have 28 days to respond to a claimant's request for reconsideration under the Motor Accident Injuries Regulation 2017. If they fail to act within this timeframe, you may escalate the matter to SIRA. However, disputes over functional recovery often require legal input, as insurers may argue that your activities do not meet the 'threshold injury' criteria under the Act.
Example: Dispute Over Household Tasks
Consider a claimant who can no longer lift groceries due to a shoulder injury. The insurer may dispute their ability to perform this task, citing a lack of 'objective evidence.' A claimant should gather evidence such as a doctor's note confirming reduced strength, a physiotherapist's assessment of daily activity limitations, and a statement from a family member about the impact on household duties. This evidence can challenge the insurer's reliance on subjective claims.
When to Contact Legal Advice
If your insurer refuses to reconsider their decision or disputes your ability to return to daily activities without providing clear clinical reasoning, seek legal advice. While internal reviews are the first step, complex disputes may require mediation through the Personal Injury Commission (PIC) or a formal challenge to the insurer's interpretation of SIRA guidelines.
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