Understanding CTP Scheme Eligibility in Bankstown
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 have been injured in a motor accident in Bankstown, NSW, and your claim for compensation has been denied or limited by your insurer, you may have the right to request an internal review. This process allows the insurer to reconsider their decision on whether you are eligible for benefits under the NSW Compulsory Third Party (CTP) scheme. The outcome of an internal review can affect your access to treatment and care benefits, weekly income payments, or damages, depending on your injury and the facts of the accident.
How Insurers Assess CTP Scheme Eligibility
Under the Motor Accident Injuries Act 2017, eligibility for CTP benefits depends on several factors. You must have been injured in a motor accident involving a motor vehicle, and the accident must have occurred in NSW. The insurer will assess whether your injuries meet the criteria for statutory benefits, including treatment and care, weekly income payments, and, in some cases, damages.
Eligibility for damages is not automatic. You must meet the threshold for a serious injury, which includes a permanent impairment of at least 15% of the whole person, or a permanent injury that results in a significant and permanent loss of function. For injuries below this threshold, you may still qualify for treatment and care benefits and weekly payments, but only for a maximum of 52 weeks if your only injuries are threshold injuries.
The Internal Review Process: What You Need to Know
If you disagree with your insurer’s decision on eligibility, you can request an internal review. This is a formal step within the insurer’s own process before you can escalate the matter to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
To begin an internal review, you must notify the insurer in writing within 60 days of receiving their decision. The insurer must acknowledge your request within 14 days and complete the review within 30 days. During the review, the insurer must consider all evidence you provide, including medical reports, accident details, witness statements, and any correspondence from your treating medical practitioners.
Evidence That Matters in an Internal Review
The strength of your claim during an internal review depends on the quality and completeness of your evidence. Key documents include:
- A detailed medical report from your treating practitioner, including diagnosis, treatment plan, and prognosis.
- A record of your injury symptoms and how they have affected your daily life and capacity to work.
- Photographs of the accident scene, vehicle damage, or visible injuries taken soon after the incident.
- A police report, if one was filed, or a written statement from a witness.
- Pay slips or a letter from your employer confirming loss of income.
If your claim involves a dispute over medical assessment, the insurer may request a second opinion. In such cases, the review will consider whether the medical evidence supports a diagnosis that qualifies under the Motor Accident Guidelines, including whether neurological signs are present in cases of soft-tissue injury.
Time Limits and Procedural Requirements
Time is critical. You must request an internal review within 60 days of receiving the insurer’s written decision. Missing this deadline may prevent you from challenging the decision through formal dispute resolution pathways. The insurer is not required to accept your request if it is late, and they may proceed to close your claim.
An internal review does not automatically change the insurer’s decision. The insurer may uphold, vary, or reverse their original determination. If the review results in a decision you still dispute, you may then apply to the Personal Injury Commission (PIC) for a formal review. The PIC will assess whether the insurer’s decision was reasonable based on the evidence.
When to Seek Independent Advice
While the internal review process is available, it is not a substitute for legal advice. The CTP scheme is complex, and decisions about eligibility, injury thresholds, and entitlements to damages can have long-term consequences. If your claim involves a dispute over a threshold injury, a spinal nerve-root injury, or a claim for damages, it is advisable to seek independent legal advice before finalising any submission.
A hypothetical example: A pedestrian in Bankstown was struck by a car at a crossing in April 2024. The insurer initially denied weekly income payments on the grounds that the injuries were minor and did not meet the threshold for serious injury. The injured person submitted a medical report showing a permanent impairment of 18% due to a spinal nerve-root injury with neurological signs. After an internal review, the insurer approved the payments. This example illustrates how medical evidence can change the outcome of a review.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.