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).
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).
CTP insurers in NSW may investigate claimed injuries through surveillance to assess the validity of a claim. If you're in Bankstown and facing a dispute over such an investigation, understanding your legal options is critical. This article explains how to challenge insurer decisions, the CTP process for disputes, and practical steps to take.
How CTP Insurers Handle Surveillance Investigations
Under the Motor Accident Injuries Act 2017, CTP insurers have a duty to investigate claims to ensure they are legitimate. Surveillance may involve monitoring a claimant’s activities, such as medical appointments, to verify injury consistency. While this process is standard, it can lead to disputes if claimants feel their privacy is breached or the investigation is unreasonable.
The NSW government’s SIRA (State Insurance Regulatory Authority) oversees CTP insurers and provides guidelines on fair claim handling. If an insurer’s surveillance investigation appears excessive or based on incomplete information, claimants may challenge the decision through formal dispute resolution channels.
Dispute Resolution Options for CTP Surveillance Disputes
- Internal Review: Most insurers offer an internal review process. You can request a written explanation of why the surveillance investigation was conducted and ask for a reassessment of your claim.
- Mediation: If the internal review doesn’t resolve the issue, mediation through the NSW Civil and Administrative Tribunal (NCAT) may be an option. Mediation allows both parties to discuss concerns with a neutral third party.
- a Formal Complaint: If mediation fails, you can file a formal complaint with SIRA. SIRA will investigate the insurer’s conduct and may require them to adjust their approach.
- Legal Action: As a last resort, claimants may seek legal advice to pursue a court challenge. However, legal action is typically reserved for cases where the insurer’s conduct is alleged to be in breach of the CTP scheme’s rules.
Practical Steps for Claimants in Bankstown
- Document Everything: Keep records of all communication with the insurer, including dates, times, and the content of messages. Note any inconsistencies in the insurer’s investigation.
- Seek Medical Evidence: Obtain medical records that confirm the injury’s severity and timeline. This can help counter claims that the injury is not as serious as reported.
- Consult a Specialist: A solicitor with experience in CTP claims can assess whether the insurer’s actions are lawful and advise on the best course of action.
Time Limits and When to Act
CTP claims must be submitted within 52 weeks of the accident if the injury is a 'threshold injury' (as defined by the Motor Accident Guidelines). However, disputes over surveillance investigations may fall outside this timeframe, depending on when the investigation began. It’s essential to act promptly to challenge any unfair practices.
Example Scenario
Imagine a claimant in Bankstown who sustained a soft-tissue injury in a car accident. The insurer conducts surveillance, noting the claimant’s attendance at multiple medical appointments. The claimant disputes the investigation, arguing it infringes on their privacy. They request an internal review, which finds the surveillance was excessive. The insurer then adjusts its approach, and the claim proceeds.
When to Seek Legal Advice
If you believe the insurer’s surveillance investigation is unreasonable, unfair, or based on incorrect information, it’s important to seek legal advice. A solicitor can help you understand your rights under the CTP scheme and guide you through the dispute resolution process.
Next Steps
CTP disputes involving surveillance investigations can be complex. The outcome depends on the specific facts of your case, the insurer’s conduct, and the evidence you present. To discuss your situation, complete the quick, no obligation enquiry form. Every claim depends on its own facts.