How SIRA Handles Insurer Complaints After 2017 Reforms
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).
The 2017 reforms to NSW’s Compulsory Third Party (CTP) scheme significantly changed how the State Insurance Regulatory Authority (SIRA) manages complaints about insurers. Before 2017, SIRA focused on resolving disputes between claimants and insurers, but the new rules shifted its role to prioritizing claim resolution. This article explains the key changes, how SIRA handles complaints under the revised system, and what injured road users need to know.
What Changed in 2017?
The Motor Accident Injuries Act 2017 (MAIA) replaced the old Motor Accidents Compensation Act 1999 (MACA), introducing a new framework for CTP claims. Key changes for SIRA complaints include:
- Reduced dispute focus: SIRA now prioritizes resolving claims based on the MAIA’s rules rather than mediating disputes. Insurers must assess claims using the Motor Accident Guidelines, and SIRA’s role is to ensure compliance.
- New complaint thresholds: Under the MAIA, claims for injuries below the ‘threshold injury’ (e.g., soft tissue injuries) are limited to 52 weeks of weekly benefits. SIRA complaints about insurer decisions must now align with these rules.
- Streamlined processes: SIRA now uses a structured approach to handle complaints, including written submissions, mediation, and formal reviews. This replaces the older, more adversarial dispute model.
Practical Steps for Making a SIRA Complaint
If you believe an insurer has wrongly denied or limited your claim, follow these steps:
- Gather evidence: Collect medical records, accident reports, witness statements, and any correspondence with the insurer. SIRA will assess whether the insurer applied the Motor Accident Guidelines correctly.
- Check claim eligibility: Ensure your injury meets the threshold injury criteria. For example, a soft tissue injury must involve a spinal nerve-root injury with neurological signs (not just radiculopathy) to qualify under the guidelines.
- Submit a written complaint: Use SIRA’s online complaint form or contact them directly. Clearly explain why you believe the insurer’s decision is incorrect, referencing the MAIA and guidelines.
- Seek mediation: If the complaint isn’t resolved, SIRA may refer the matter to a mediator. This step is designed to avoid lengthy disputes and ensure claims are processed efficiently.
Time Limits and Dispute Options
Under the MAIA, claimants must notify SIRA of a complaint within 6 months of the insurer’s decision. If you miss this deadline, SIRA may refuse to act. For disputes over weekly benefits or treatment payments, the 52-week limit for threshold injuries applies, meaning claims beyond this period may not qualify for further benefits.
If you’re unsure whether your complaint fits within SIRA’s new rules, it’s important to act quickly. The 2017 reforms mean that disputes are now resolved under a different legal framework, and older processes no longer apply.
Example: A Claimant’s Situation
Consider a scenario where a claimant is denied weekly income payments for a soft tissue injury. Under the MAIA, the insurer must assess whether the injury meets the threshold criteria. If the claimant believes the injury qualifies but the insurer rejected it, they can submit a complaint to SIRA. SIRA will review whether the insurer applied the guidelines correctly, not whether the claimant is ‘blaming’ the insurer.
When to Seek Legal Advice
While SIRA provides a structured process for complaints, complex cases, such as disputes over long-term care needs or overlapping workers’ compensation claims, may require legal assistance. Always ensure your complaint includes detailed evidence and references to the MAIA and guidelines.
Next Steps
The 2017 reforms have changed how SIRA handles insurer complaints, making it essential for claimants to understand the new rules. If you’re unsure whether your complaint fits within the revised system, or if you need help preparing your case, complete the quick, no obligation enquiry form to request contact about your circumstances.