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 Compulsory Third Party (CTP) claim on the Central Coast has been rejected after an insurer's internal review, you have options to challenge the decision. This article explains how to resolve disputes under NSW CTP rules, including SIRA's processes and practical steps for claimants.
How to Challenge an Insurer's Internal Review Decision
Under NSW CTP rules, insurers must first consider your claim internally before escalating it to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). If your claim is rejected, you can request a review of the internal decision. SIRA provides a structured process for resolving disputes, including:
- Requesting a reconsideration: You can ask the insurer to review its decision by providing additional evidence or clarifying your claim.
- Dispute resolution through SIRA: If the insurer refuses to reconsider, you can escalate the matter to SIRA. SIRA will assess whether the insurer's decision meets the legal standards for CTP claims.
- Medical dispute pathways: If the claim involves a medical assessment, you may need to challenge the insurer's interpretation of your injury's severity or treatment needs.
Practical Steps and Evidence That Matter
To challenge an insurer's decision, you must provide evidence that supports your claim. Key documents include:
- Medical records showing your injury meets the threshold injury definition under the Motor Accident Injuries Act 2017.
- Accident reports, witness statements, and photographs to establish the incident.
- Proof of income or expenses if you're seeking weekly benefits or treatment and care payments.
- Correspondence with the insurer showing the internal review process.
If your claim involves a medical dispute, ensure your medical records include assessments from a registered medical practitioner. SIRA may also require a second opinion if the insurer's assessment is contested.
Time Limits and When to Seek Advice
CTP claims have strict time limits. You must notify your insurer of your claim within 90 days of the accident. If the insurer rejects your claim, you have 28 days to request a reconsideration. If the insurer still refuses to adjust its decision, you must escalate the matter to SIRA within 28 days of receiving the final decision.
Disputes over medical assessments or injury severity must be resolved within these timeframes. Delays can result in lost opportunities to challenge the insurer's decision. If your claim involves complex medical evidence or disputes over injury thresholds, seek legal advice promptly.
A Hypothetical Example
Imagine a cyclist on the Central Coast who was injured in a collision. The insurer rejects the claim, arguing the injury does not meet the threshold injury definition. The cyclist requests a reconsideration, providing medical records showing a spinal nerve-root injury with neurological signs. The insurer still denies the claim, so the cyclist escalates the matter to SIRA. SIRA reviews the medical evidence and determines the injury meets the threshold, leading to a revised decision.
Next Steps
CTP disputes on the Central Coast require careful navigation of insurer processes and SIRA guidelines. If your claim has been rejected after an internal review, act quickly to challenge the decision. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.