What CTP Insurers Investigate During Surveillance
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).
In New South Wales, Compulsory Third Party (CTP) insurers have the right to investigate claimed injuries and activities during disputes. This process, often referred to as 'surveillance, ' involves assessing whether the injury and its impact align with the claimant's stated circumstances. While the Personal Injury Commission (PIC) oversees CTP claims, insurers may request additional information to verify the validity of a claim.
Insurers typically investigate evidence such as medical records, activity logs, and witness statements. They may also request details about the claimant's daily routines, work capacity, and adherence to treatment plans. The goal is to ensure that benefits are paid for legitimate injuries and that claimants are not exaggerating their condition.
Legal Framework for CTP Surveillance
The Motor Accident Injuries Act 2017 (MAIA) governs CTP claims in NSW. Under this legislation, insurers must act reasonably when assessing claims. Section 4.4 of the MAIA specifies that weekly benefits and treatment payments are limited to 52 weeks if the injury is classified as a 'threshold injury', a term defined in the Motor Accident Guidelines.
SIRA (State Insurance Regulatory Authority) provides authoritative guidance on CTP claims. Its guidelines clarify that insurers may request additional information to verify the 'only injuries' test, which determines whether a claimant is eligible for ongoing benefits. This process must comply with the MAIA's requirements for fairness and transparency.
Practical Steps for Claimants in Disputes
When disputes arise from surveillance findings, claimants should take the following steps:
- Document all medical interactions and treatment plans.
- Maintain a detailed activity log showing how the injury affects daily life.
- Respond to insurer requests for information promptly and in writing.
- Seek independent medical opinions if the claimant believes their condition is not being accurately assessed.
Claimants should also be aware of the 52-week limit for certain benefits. If an injury is classified as a threshold injury, weekly payments may stop after 52 weeks, even if the claimant is still recovering. This distinction is critical during disputes.
Dispute Resolution and When to Seek Advice
If an insurer disputes a claim, the claimant has the right to request an internal review. The PIC's medical dispute pathway allows claimants to challenge decisions by providing additional evidence or expert opinions. However, it's important to note that a challenge does not guarantee a changed decision.
Disputes may also involve the PIC's role in mediating between claimants and insurers. Claimants should consider seeking legal advice if the dispute escalates, particularly if the insurer's actions appear unreasonable or if the claimant feels their rights under the MAIA are being violated.
Hypothetical Example: A Claimant's Experience
Consider a claimant who sustained a soft-tissue injury in a car accident. After 52 weeks, the insurer disputes ongoing weekly payments, arguing the injury is a 'threshold injury.' The claimant must demonstrate that their injury meets the MAIA's criteria for a 'threshold injury' and that their recovery is not yet complete. This requires medical evidence showing that the injury has not resolved and that the claimant's daily activities are still impacted.
Next Steps for Claimants in Auburn
CTP disputes can be complex, and the outcome often depends on the specific facts of the case. Claimants in Auburn should ensure they understand the legal boundaries of insurer investigations and the evidence required to support their claim. If the dispute involves surveillance findings, it may be necessary to seek legal advice to navigate the process effectively.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.