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 an injured road user in Armidale NSW and your CTP claim was denied or rejected, you have legal rights to challenge the decision through an insurer's internal review process. This article explains the early-stage procedures under NSW law, including how to request a reconsideration, what evidence to prepare, and when to escalate to SIRA or the Personal Injury Commission (PIC). The process is governed by the Motor Accident Injuries Act 2017 and SIRA's mandatory dispute resolution protocols.
Early Steps for Disputing a CTP Claim Decision
Under NSW law, insurers must conduct an internal review of denied claims before escalating to SIRA or the PIC. This is a mandatory step to resolve disputes without immediately involving higher authorities. To begin, you must:
- Submit a written request for reconsideration within 28 days of receiving the decision (per SIRA guidelines). This must clearly state your disagreement and reference the specific clause or policy provision you believe was misapplied.
- Provide supporting evidence such as medical records, accident reports, witness statements, and any documentation showing the insurer's decision was based on incorrect information.
- Include a timeline of all communications with the insurer, including dates of claim submissions, correspondence, and any previous disputes.
The insurer must respond in writing within 21 days, explaining their decision and offering a revised outcome. If the review is unsuccessful, you may escalate the matter to SIRA or the PIC.
What Evidence Matters in an Internal Review?
SIRA requires claimants to demonstrate that the insurer's decision was legally or factually flawed. Key evidence includes:
- Medical documentation showing the injury meets the threshold injury definition under the Motor Accident Injuries Act 2017 (e.g., spinal nerve-root injury with neurological signs).
- Accident reports from police or traffic authorities, including details of vehicle movements, road conditions, and any contributing factors.
- Witness statements from bystanders, other drivers, or pedestrians who can corroborate your account.
- Photographs of the accident scene, vehicle damage, and any visible injuries.
- Financial records showing lost income or additional expenses directly caused by the accident.
For example, if an insurer denies a claim for a soft-tissue injury due to a lack of 'radiculopathy' (a specific clinical sign), you may need to provide a doctor's report showing neurological signs that meet the Motor Accident Guidelines.
Time Limits and Dispute Resolution Options
You must initiate an internal review within 28 days of the insurer's decision. If the review is unsatisfactory, you can escalate to SIRA or the PIC within 21 days of the review outcome. However, you must act quickly: the time limit for disputing a CTP claim is generally 3 years from the date of the accident, but this may vary depending on the type of claim.
If the insurer refuses to conduct a review, you may need to file a complaint with the NSW Ombudsman or seek legal advice. Remember, an internal review does not guarantee a changed decision, the insurer may still uphold their original ruling.
When to Seek Legal Advice
If your claim involves complex medical evidence, disputes over fault, or potential overlaps with workers' compensation or other benefits, you should consult a solicitor. Legal advice is particularly important if:
- The insurer refuses to conduct an internal review.
- You believe the claim was denied due to contributory fault or threshold injury rules.
- You need to challenge a decision to terminate weekly benefits after 52 weeks.
Next Steps for Injured Road Users
If your CTP claim has been denied or you're unsure about the insurer's decision, take these steps:
- Request an internal review in writing within 28 days.
- Gather all relevant evidence to support your case.
- Monitor the insurer's response and escalate if necessary.
- Contact LegalAdvice.com.au for free, no obligation advice if your claim involves complex issues.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.