How SIRA Guides Insurer Internal Reviews for CTP Claims in NSW
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 has been denied or is under dispute, understanding how insurers handle internal reviews is critical. In New South Wales, the State Insurance Regulatory Authority (SIRA) provides authoritative guidance on how insurers should assess and reconsider claims. This article explains the process, how SIRA’s rules apply, and steps you can take if your claim is contested.
The NSW CTP Rules Behind the Question
Under the Motor Accident Injuries Act 2017, insurers must review disputed claims before escalating them to SIRA or the Personal Injury Commission (PIC). SIRA’s guidelines clarify that insurers must consider factors like medical evidence, claimant’s injury severity, and compliance with the Motor Accident Guidelines during internal reviews. For example, if an insurer denies a claim for a soft-tissue injury, it must justify why the injury doesn’t meet the threshold injury criteria outlined in the Act.
Practical Steps and Evidence That Usually Matter
When disputing a claim, insurers typically require:
- Medical records showing the injury’s severity and link to the accident
- Accident reports or witness statements
- Evidence of income loss or treatment costs
- Proof of the insurer’s decision (e.g., written correspondence)
SIRA’s guidelines stress that insurers must provide a clear explanation for denying a claim. If they fail to do so, claimants may have grounds to escalate the matter. For instance, if an insurer rejects a claim without referencing the Motor Accident Guidelines, this could be a valid reason to challenge their decision.
Time Limits, Disputes and When to Seek Advice
Insurers must act within 28 days of receiving a claim to issue a decision, per SIRA’s rules. If they fail to respond within this timeframe, the claim may be deemed ‘out of time’ for internal review. If your claim is denied, you can request an internal review within 28 days of the decision. If the insurer refuses to reconsider, you may need to escalate to SIRA or the PIC. However, note that disputing a claim does not guarantee a change in decision. SIRA’s role is to ensure insurers follow the law, not to make new rulings.
A Hypothetical Example
Imagine a claimant who suffered a soft-tissue injury in a car accident. The insurer denies the claim, arguing the injury doesn’t meet the threshold injury definition. The claimant requests an internal review, providing medical evidence showing neurological signs consistent with a spinal nerve-root injury. If the insurer’s review still rejects the claim without referencing the Motor Accident Guidelines, the claimant may have a valid basis to escalate to SIRA.
When to Seek Legal Advice
If your claim is denied, or if you’re unsure how to challenge the decision, it’s important to seek advice. SIRA’s guidelines are complex, and insurers may use technicalities to deny claims. A legal professional can help you assess whether your claim meets the criteria for review or escalation. Always act within the 28-day timeframe for internal reviews to avoid missing procedural deadlines.
Next Steps
CTP claims depend on the specific facts of your case. While SIRA provides clear rules for insurers, navigating disputes requires careful attention to evidence and deadlines. If you’re facing a denied claim, consider contacting a legal professional to review your options. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.