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 disputing a decision by an NSW Compulsory Third Party (CTP) insurer in Bathurst, the State Insurance Regulatory Authority (SIRA) provides formal complaint and dispute resolution pathways. This guide explains how to raise concerns about insurer conduct, the options available under the NSW CTP scheme, and when to seek legal advice.
SIRA's Role in CTP Dispute Resolution
SIRA oversees the NSW CTP scheme, ensuring insurers comply with the Motor Accident Injuries Act 2017 and its regulations. If an insurer denies a claim, delays payments, or refuses to consider evidence, you can lodge a complaint with SIRA. The authority investigates complaints about insurer conduct, including:
- Refusal to pay benefits or damages
- Unreasonable delays in processing claims
- Failure to consider medical evidence
SIRA's complaint process is distinct from legal action. It focuses on resolving disputes about insurer behavior, not the merits of your claim. For example, if an insurer rejects a claim without providing a valid reason, SIRA may intervene to ensure compliance with scheme rules.
Practical Steps for Lodging a SIRA Complaint
To begin a complaint, you must first exhaust internal insurer review processes. Most insurers offer an internal appeals process before you can escalate to SIRA. Key steps include:
- Requesting an internal review: Contact the insurer's customer service or claims department to formally request a review of their decision. Provide evidence such as medical reports, accident records, and correspondence.
- Lodging a SIRA complaint: If the insurer's internal review is unsatisfactory, you can submit a written complaint to SIRA within 28 days of the insurer's final decision. The complaint must clearly state the issue and include supporting documents.
- SIRA investigation: SIRA will assess the complaint and may request additional information from the insurer or you. The process typically takes up to 28 days, though complex cases may take longer.
Dispute Resolution Options Beyond SIRA
If SIRA's investigation does not resolve the dispute, you may need to pursue other avenues. These include:
- Mediation through the NSW Civil and Administrative Tribunal (NCAT): NCAT can facilitate mediation to resolve disputes about claim valuations or insurer conduct.
- Legal action: If the insurer's behavior breaches the CTP scheme rules, you may seek legal remedies. However, legal action is typically a last resort and requires evidence of regulatory breaches.
Evidence That Matters in CTP Disputes
When disputing an insurer's decision, the following evidence is critical:
- Medical records: Show the nature and severity of injuries, including opinions from medical practitioners.
- Accident reports: Police reports, witness statements, and photographs can support your claim.
- Insurer correspondence: Emails, letters, or forms from the insurer that demonstrate delays or refusal to consider evidence.
- Financial records: Proof of income loss or out-of-pocket expenses.
Time Limits and When to Seek Advice
You must lodge a SIRA complaint within 28 days of the insurer's final decision. If you miss this deadline, you may lose the right to challenge the insurer's conduct through SIRA. However, time limits for legal action vary depending on the nature of the dispute.
If you're unsure whether your case meets SIRA's criteria for investigation, or if the insurer's conduct appears to breach the CTP scheme rules, seek legal advice. A solicitor can assess whether your dispute falls within SIRA's jurisdiction or if other remedies are available.
Example Scenario
Consider a case where an insurer refuses to pay weekly income benefits after a threshold injury. The injured person lodges an internal review, but the insurer maintains its decision. They then submit a SIRA complaint, citing the insurer's failure to consider medical evidence under the Motor Accident Guidelines. SIRA investigates and finds the insurer's decision was inconsistent with scheme rules, leading to a revised payment.
Next Steps
CTP disputes involving insurer conduct can be complex. While SIRA provides a formal pathway for complaints, the process depends on the specific circumstances of your case. To request contact about your circumstances, complete the quick, no obligation enquiry form.