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 in regional NSW and your insurer has refused to approve your claim for returning to daily activities after a motor accident, you may have grounds to dispute their decision. This article explains how to raise a complaint with NSW's Motor Accident Claims Authority (SIRA), what evidence is needed, and how to challenge an insurer's assessment of your recovery progress.
SIRA Rules for Disputing Insurer Decisions
SIRA oversees the Compulsory Third Party (CTP) scheme in NSW and has specific rules for handling complaints about insurers' claim assessments. Under the Motor Accident Injuries Act 2017, insurers must evaluate claims based on medical evidence and the injury's impact on daily life. If you believe an insurer has wrongly denied or limited your ability to return to daily activities, you can:
- Submit a formal complaint to SIRA through their online portal or by mail.
- Request a review of the insurer's decision by providing additional medical evidence or clarification.
- Seek mediation if the insurer refuses to reconsider their assessment.
SIRA's guidelines state that insurers must consider all relevant medical records, including reports from doctors, physiotherapists, and occupational therapists, when determining recovery progress. If your insurer has not adequately reviewed your medical evidence, this could form the basis of a complaint.
Evidence to Support a SIRA Complaint
To challenge an insurer's decision, you'll need to provide evidence that:
- Medical records showing your injury's impact on daily activities (e.g., difficulty with mobility, household tasks, or work).
- Accident reports or witness statements confirming the incident's circumstances.
- Insurer correspondence detailing their refusal to approve daily activity resumption.
- Expert opinions from medical professionals about your recovery timeline.
For example, if you're a regional resident with a soft-tissue injury (threshold injury) and your insurer denies weekly benefits after 52 weeks, you must show that your injury meets the criteria under the Motor Accident Guidelines. SIRA will assess whether the insurer's decision aligns with these guidelines.
Time Limits and When to Seek Advice
You have 28 days to dispute an insurer's decision under the Motor Accident Injuries Act 2017. If the insurer's refusal to approve daily activity resumption is based on incomplete or incorrect medical evidence, you should:
- Contact your treating medical practitioner to obtain a detailed report on your recovery.
- Submit a written complaint to SIRA within the 28-day period.
- Request a review of the insurer's decision by providing additional evidence.
If the insurer ignores your complaint or refuses to reconsider, you may need to seek independent legal advice. SIRA can also provide guidance on how to escalate disputes to the NSW Civil and Administrative Tribunal (NCAT) if necessary.
Practical Steps for Regional NSW Claimants
In regional areas, accessing legal support or medical specialists may be more challenging. To strengthen your case:
- Consult a local physiotherapist or occupational therapist to assess your ability to return to daily activities.
- Use SIRA's online claim portal to submit evidence and track your complaint.
- Contact the NSW Department of Communities, Housing and Human Services for assistance with navigating regional healthcare services.
Remember, insurers must act reasonably when assessing recovery progress. If you believe their decision is unfair or based on incomplete information, you have the right to challenge it through SIRA.
When to Seek Legal Advice
If your insurer has:
- Refused to approve weekly benefits after 52 weeks.
- Denied your claim without providing a clear explanation.
- Refused to consider new medical evidence.
You should seek legal advice to explore options such as disputing the insurer's assessment or applying for a review by NCAT. Legal professionals can also help you understand whether your claim meets the threshold injury criteria under the Motor Accident Guidelines.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.