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 Compulsory Third Party (CTP) insurer rejects your claim or disputes the amount of compensation, you have options to challenge their decision. This article explains how to request an internal review, escalate disputes to the Personal Injury Commission (PIC) or SIRA, and what evidence matters when resolving disagreements in Albury. Time limits and practical steps are outlined to help injured claimants understand their rights under the Motor Accident Injuries Act 2017.
How to Challenge an Insurer's Internal Review Decision
NSW CTP insurers must provide a written explanation if they deny or reduce a claim. Claimants can request a reconsideration by submitting a formal written objection within 28 days of receiving the decision. This process allows the insurer to reassess their assessment based on new evidence or clarification.
If the insurer refuses to reconsider or the claimant is unsatisfied with the outcome, the next step is to escalate the dispute to the PIC. The PIC handles disputes about the amount of compensation or the insurer's refusal to pay. You must apply to the PIC within 28 days of the insurer's final decision.
For disputes involving the interpretation of the law or policy, the claimant can request a review by SIRA. SIRA will assess whether the insurer's decision aligns with the Motor Accident Guidelines and the relevant legislation.
SIRA's Role in Resolving Disputes
SIRA provides authoritative guidance on CTP claims and handles disputes where the insurer's decision is challenged. When a claimant disputes an insurer's internal review, SIRA will review the case to ensure the decision complies with the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines.
SIRA's role includes:
- Assessing whether the insurer applied the correct legal standards
- Reviewing medical evidence and injury assessments
- Determining if the claimant is entitled to additional benefits or damages
SIRA's decisions are binding unless the claimant appeals to the NSW Civil and Administrative Tribunal (NCAT). This process ensures that claimants receive fair treatment when insurers disagree with their assessments.
Practical Steps and Evidence to Gather
To resolve a dispute with an insurer, claimants must provide clear evidence to support their case. Key documents include:
- A copy of the insurer's written decision and explanation
- Medical records confirming the injury and its impact
- Evidence of lost income or additional expenses
- Witness statements or accident reports
Claimants should also keep records of all correspondence with the insurer and any attempts to resolve the dispute through internal channels. This evidence is critical when escalating the matter to the PIC or SIRA.
Time Limits and When to Seek Advice
NSW CTP claimants must act within strict time limits. The 28-day window to request an internal review or escalate to the PIC is critical. Missing this deadline can result in the claim being dismissed.
If the claimant is unsure about their options or the insurer's decision, seeking legal advice is advisable. A solicitor can help identify whether the insurer applied the correct legal standards and whether the claimant is entitled to additional compensation.
Example Scenario
Consider a claimant who was injured in a car accident in Albury. The insurer denied the claim, stating the injury did not meet the threshold injury definition. The claimant requested a reconsideration, providing medical evidence of a spinal nerve-root injury with neurological signs. After the insurer refused to change its decision, the claimant escalated the matter to the PIC. The PIC reviewed the medical records and found the injury met the threshold injury criteria, leading to a revised claim.
Next Steps
If you are facing a dispute with your NSW CTP insurer after an internal review, it is important to act quickly. Time limits apply, and the process involves multiple stages of review. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.