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 you're in rural NSW and your insurer has refused to approve your return to daily activities after a motor accident, you may have grounds to dispute their decision. The NSW Motor Accident Injuries Act 2017 and SIRA (State Insurance Regulatory Authority) govern these claims, and rural claimants have specific rights to challenge decisions. This article explains how to raise a complaint with SIRA, what evidence is needed, and how the process works for rural areas.
SIRA's Role in Disputing Daily Activity Decisions
SIRA oversees the Compulsory Third Party (CTP) scheme in NSW and ensures insurers comply with the Motor Accident Injuries Act 2017. When an insurer denies or limits approval of daily activities, claimants can request a review through SIRA. The regulator assesses whether the insurer's decision aligns with the scheme's rules, including medical evidence and the nature of the injury.
Key points to understand:
- SIRA does not make decisions about daily activities itself. Instead, it reviews whether the insurer has followed the correct process.
- Rural claimants may face additional challenges, such as limited access to specialist medical assessments or delays in accessing services. These factors can impact the insurer's assessment.
- SIRA considers whether the insurer has acted reasonably based on the evidence provided. This includes medical reports, treatment records, and your ability to perform daily tasks.
Practical Steps to Dispute an Insurer's Decision
To challenge an insurer's refusal to approve daily activities, follow these steps:
- Gather medical evidence: Obtain detailed reports from your treating medical practitioner confirming your ability (or inability) to perform daily activities. This includes assessments of mobility, pain levels, and any restrictions.
- Document your daily activities: Keep a record of what you can and cannot do, including notes on how the injury affects your routine. This helps demonstrate the practical impact of the injury.
- Contact SIRA directly: Use SIRA's official complaint process to request a review. You can submit your complaint through their website or by phone. Ensure you reference the specific insurer's decision and provide all relevant evidence.
- Seek clarification on insurer's reasoning: Before lodging a complaint, ask the insurer for written details of why they denied your request. This helps identify gaps in their assessment and strengthens your case.
Evidence That Matters Most
SIRA places significant weight on medical evidence when assessing daily activity claims. Key documents include:
- Medical reports from registered practitioners confirming the nature and severity of your injury.
- Treatment records showing the progression of your recovery and any ongoing limitations.
- Statements from your treating doctor about how the injury affects your ability to perform daily tasks.
- Witness statements from family members or colleagues describing your daily activities and any changes.
- Photographs or videos of your living environment that highlight accessibility challenges or mobility issues.
In rural areas, claimants may need to rely on local medical facilities or telehealth services. Ensure that all evidence is clearly linked to your specific circumstances and the insurer's decision.
Time Limits and When to Seek Advice
You have 52 weeks from the date of the accident to claim certain benefits under the CTP scheme. However, disputes about daily activities can extend beyond this period, especially if the insurer's decision is based on incomplete or delayed information.
If you believe the insurer has acted unfairly, you should:
- Lodge a complaint with SIRA within 28 days of receiving their decision. This is the statutory time limit for disputing insurer actions.
- Seek legal advice if your complaint is rejected or if the insurer refuses to provide a written explanation. A solicitor can help you understand your options, including mediation or formal dispute resolution.
Example: A Rural Claimant's Experience
Consider a claimant in a remote NSW town who suffered a soft tissue injury in a car accident. The insurer denied approval for daily activities, citing a lack of medical evidence. The claimant submitted detailed reports from their local GP and a specialist telehealth consultation, which demonstrated the injury's impact on their ability to work and manage household tasks. SIRA reviewed the evidence and found the insurer had not followed the correct process, leading to a revised decision.
Next Steps for Rural Claimants
If your insurer has refused to approve daily activities, the first step is to contact SIRA and request a review. Ensure you provide all relevant evidence, including medical reports and documentation of your daily challenges. If your complaint is rejected, consider seeking legal advice to explore further options.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.