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 you're an injured road user in the Blue Mountains or Nepean area and believe an insurer mishandled your daily activities claim under the NSW Compulsory Third Party (CTP) scheme, you can formally complain to the State Insurance Regulatory Authority (SIRA). This article explains the process, evidence needed, and how SIRA evaluates such complaints.
What is a Daily Activities Claim?
Daily activities claims under the Motor Accident Injuries Act 2017 cover injuries that prevent someone from performing everyday tasks like cooking, shopping, or personal hygiene. These claims are distinct from compensation for pain and suffering or lost income. SIRA oversees insurers’ handling of these claims, ensuring they comply with the CTP scheme rules.
How to Lodge a SIRA Complaint
To complain about an insurer’s management of your daily activities claim, follow these steps:
- Contact the insurer first - Review the insurer’s decision letter and check if they’ve applied the correct CTP rules. If you disagree, request a review in writing.
- Submit a written complaint - Use SIRA’s online complaint form or download the official complaint template from SIRA’s website. Clearly state:
- The date of your accident and claim
- The insurer’s name and policy number
- How the insurer’s actions affected your daily activities
- Any specific CTP rules you believe were misapplied
- Include supporting evidence - Attach documents like medical reports, activity logs, and correspondence with the insurer.
- Wait for a response - SIRA will investigate and notify you of their decision within 28 days.
Evidence SIRA Requires
SIRA evaluates complaints based on whether insurers followed the CTP scheme’s rules. Key evidence includes:
- Medical evidence - Doctor’s reports confirming your injury prevents daily activities. For example, if you can’t walk to the shops due to a knee injury, this must be documented.
- Activity logs - Keep a diary of tasks you can’t perform, like bathing or dressing, and how this impacts your life.
- Insurer correspondence - Emails or letters showing the insurer denied your claim or refused to cover daily activities.
- Witness statements - Testimonies from family or friends about how your injury affects your daily routine.
How SIRA Assesses Complaints
SIRA reviews complaints by checking:
- Whether the insurer applied the correct CTP rules to your injury
- If your daily activities claim meets the 'threshold injury' criteria under the Motor Accident Guidelines
- If the insurer’s decision was reasonable based on the evidence
For example, if an insurer refuses to cover a claim for a soft-tissue injury (like a whiplash) that limits your ability to walk, SIRA will assess if the injury meets the spinal nerve-root qualification in the guidelines.
Time Limits and When to Seek Advice
You must lodge a complaint with SIRA within 28 days of receiving the insurer’s decision. If you’re unsure about the insurer’s actions or need help preparing your complaint, contact a legal professional. SIRA can also provide free assistance through its online support portal.
Final Steps
If you’re in the Blue Mountains or Nepean and believe your insurer mishandled your daily activities claim, act quickly. SIRA’s process ensures insurers follow the CTP scheme’s rules, but you must provide clear evidence of how their actions affected your recovery. For personalized advice, complete the quick, no obligation enquiry form to request contact about your circumstances.