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've lodged a complaint with the State Insurance Regulatory Authority (SIRA) about a Compulsory Third Party (CTP) insurer in Newcastle or Hunter, you may need to understand your options for resolving disputes. SIRA oversees the NSW CTP scheme governed by the Motor Accident Injuries Act 2017, and its processes apply consistently across the state. This article explains how to escalate disputes, what evidence matters, and when to seek legal assistance.
How SIRA Handles CTP Disputes
SIRA ensures insurers comply with the Motor Accident Injuries Act 2017 and its regulations. If your complaint relates to a CTP claim, SIRA will review the insurer’s conduct, including whether benefits were correctly calculated or payments were delayed. For example, if an insurer refuses to pay for a threshold injury or disputes the need for treatment, SIRA will assess whether the insurer followed the Motor Accident Guidelines.
Practical Steps for Escalating Disputes
- Document your complaint: Keep records of all communication with the insurer, including dates, correspondence, and any refusal to pay. SIRA requires written evidence of disputes.
- Submit a formal complaint: Use SIRA’s online complaint form or contact their Newcastle office directly. Ensure you reference the specific claim number and detail the issue, such as delayed payments or incorrect benefit calculations.
- Provide medical evidence: SIRA may require medical reports to assess injury severity. For threshold injuries, ensure your treating practitioner documents neurological signs or spinal nerve-root injuries as defined in the Motor Accident Guidelines.
- Request a review: If the insurer disputes your claim, SIRA will conduct a review. This may involve a medical expert assessing your injury’s alignment with the guidelines.
Time Limits and Dispute Options
SIRA typically responds to complaints within 28 days, though complex cases may take longer. If the insurer disputes the claim, you may need to escalate to the Personal Injury Commission (PIC) for a medical dispute review. The PIC can assess whether the insurer’s medical opinion aligns with the Motor Accident Guidelines. Note that challenges to SIRA decisions do not guarantee a changed outcome, and the insurer may still uphold its original decision.
When to Seek Legal Advice
If your dispute involves:
- A claim for lifetime care or weekly income payments
- A disagreement over the threshold injury definition
- A dispute over the 52-week limit for statutory benefits
- A need to challenge the insurer’s medical assessment
You should consult a solicitor. Legal advice can help you navigate the PIC process, challenge incorrect benefit calculations, or pursue a common law damages claim if the insurer’s conduct was unreasonable.
Example Scenario
Consider a claimant in Newcastle who sustained a soft-tissue injury after a car accident. The insurer disputes the injury as a threshold injury, refusing to pay for treatment. The claimant lodges a SIRA complaint, providing medical evidence of spinal nerve-root injury. SIRA reviews the claim, finds the injury meets the threshold definition, and orders the insurer to pay. If the insurer refuses, the claimant may seek legal help to challenge the insurer’s stance.
Next Steps
SIRA’s dispute resolution process is designed to address complaints about CTP insurers, but it may not resolve all issues. If your case involves complex medical disputes, delayed payments, or a need to challenge the insurer’s interpretation of the guidelines, legal assistance is advisable. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.