How SIRA Handles Complaints About Claimants' Functional Recovery
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).
If an insurer in New South Wales raises concerns about a claimant's ability to return to daily activities after a motor accident, the State Insurance Regulatory Authority (SIRA) oversees the process under the Motor Accident Injuries Act 2017. SIRA evaluates complaints by assessing whether the claimant’s functional recovery aligns with medical evidence and the scheme’s rules. This article explains how insurers can challenge claims, what evidence is required, and the steps to resolve disputes in Bega.
Legal Framework for SIRA Complaints
Under the Motor Accident Injuries Act 2017, insurers must act reasonably when disputing claims. SIRA’s role is to ensure claims are processed fairly, based on the Motor Accident Guidelines. Key principles include:
- Threshold injuries (soft tissue injuries with no whole-person impairment) are limited to 52 weeks of benefits under s 4.4 of the Act.
- Functional recovery must be supported by medical evidence, such as a doctor’s assessment of the claimant’s ability to perform daily tasks.
- Insurers cannot dispute a claim solely based on a claimant’s subjective account of their recovery.
SIRA also enforces the Motor Accident Injuries Regulation 2017, which outlines how insurers must handle complaints and provide claimants with opportunities to respond.
Evidence Required for Insurer Complaints
When an insurer raises a complaint about a claimant’s return to daily activities, they must provide:
- Medical records confirming the claimant’s injury and recovery progress
- Evidence of the claimant’s current functional capacity (e.g., activity logs, occupational therapy reports)
- A written explanation of why the claimant’s recovery does not meet the scheme’s criteria
Claimants should review the insurer’s complaint and provide any additional evidence, such as:
- Statements from healthcare professionals about their ability to perform daily tasks
- Documentation of any changes in their condition since the accident
- Proof of any attempts to return to work or independent living
Resolving Disputes in Bega NSW
If an insurer’s complaint leads to a dispute, the following steps may apply:
- SIRA review: The insurer must submit the complaint to SIRA for assessment. SIRA will consider the claimant’s evidence and determine if the insurer’s concerns are valid.
- Mediation: SIRA may offer mediation to resolve the dispute without further legal action.
- Formal dispute: If mediation fails, the insurer may escalate the matter to the NSW Civil and Administrative Tribunal (NCAT) for a formal review.
Claimants should seek legal advice if they believe an insurer’s complaint is unfounded or based on incomplete evidence.
When to Seek Legal Advice
Claimants should consult a solicitor if:
- The insurer’s complaint is based on incomplete or misleading evidence
- They disagree with SIRA’s decision on a functional recovery assessment
- They need assistance with submitting evidence to support their claim
Legal professionals can help ensure claimants understand their rights under the CTP scheme and navigate disputes with insurers.
Next Steps
CTP entitlements depend on the date of the accident, the nature of the injury, and the evidence provided. If you are in Bega and facing a dispute with an insurer about your ability to return to daily activities, it is important to act promptly. Complete the quick, no obligation enquiry form to request contact about your circumstances.