Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
Insurers in New South Wales assess liability for Compulsory Third Party (CTP) claims through internal reviews to determine if a claimant meets the scheme's requirements. This process is guided by the Motor Accident Injuries Act 2017 (MAIA) and SIRA guidelines. If an insurer denies or disputes a claim, claimants can request a reconsideration before escalating to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA). Understanding how insurers evaluate liability is critical for claimants in Greater Sydney seeking fair outcomes.
How Insurers Evaluate CTP Liability
When a claimant lodges a CTP claim, insurers assess liability by checking if the accident meets the scheme's criteria. Under the MAIA, liability is determined based on the accident's circumstances, not fault. Insurers use SIRA's guidelines to evaluate whether the claimant's injuries fall within the 'threshold injury' definition, which includes soft tissue injuries like whiplash. For example, an insurer may dispute a claim if the claimant's injuries are deemed non-serious or if the accident occurred outside the scheme's scope, such as on private property.
Insurers also consider the claimant's medical evidence, including treatment records and medical reports, to assess the injury's severity. If the claimant's injuries are classified as 'threshold injuries, ' the insurer may limit benefits after 52 weeks, as outlined in MAIA s 4.4. This means claimants must demonstrate that their injuries exceed the threshold to qualify for ongoing payments.
Practical Steps for Claimants
When disputing an insurer's liability decision, claimants should take the following steps:
- Request an internal review: Insurers must provide a written explanation for denying a claim. Claimants can ask for a reconsideration by submitting additional evidence, such as medical opinions or accident reports.
- Gather medical evidence: Medical records from doctors, physiotherapists, or specialists are crucial. These documents must show that the injury meets the threshold injury definition under SIRA guidelines.
- Document the accident: Police reports, witness statements, and photographs of the accident scene can support the claimant's case. For example, a witness confirming the accident's location and circumstances may help challenge an insurer's dispute.
- Seek independent medical assessment: If the insurer disputes the injury's severity, claimants may need an independent medical opinion to prove the injury's impact.
Time Limits and Dispute Options
CTP claims have strict time limits. Under the MAIA, claimants must notify the insurer within 90 days of the accident. If the insurer disputes liability, claimants can request a review within 28 days of the denial. If the insurer refuses to reconsider, the claimant may escalate the matter to the PIC or SIRA. However, it's important to note that disputing an insurer's decision does not guarantee a change. The PIC or SIRA will assess the claim based on the evidence and the scheme's requirements.
When to Seek Legal Advice
Claimants should consult a solicitor if the insurer's decision is unclear, if the claimant is unsure about their rights, or if the dispute involves complex issues like workers' compensation overlap. A lawyer can help navigate the CTP scheme's requirements and ensure the claimant's interests are protected. For example, a solicitor may challenge an insurer's interpretation of 'threshold injury' or help prepare a case for review by the PIC.
Example Scenario
Consider a claimant who was in a car accident in Sydney and sustained whiplash. The insurer disputes the claim, arguing the injury is not serious enough to qualify. The claimant provides medical records showing ongoing neck pain and reduced mobility, which meet the threshold injury criteria under SIRA guidelines. The insurer then reviews the claim and may reconsider its decision based on the evidence.
Next Steps
CTP claims depend on the accident's date, the injury's severity, and the claimant's evidence. If you're unsure about your insurer's decision or need help challenging a denial, complete the quick, no obligation enquiry form to request contact about your circumstances. Every claim depends on its own facts, and seeking professional advice can help ensure you understand your options.