If you're disputing a decision by a CTP insurer in New South Wales, you have formal processes to challenge their decision under the Motor Accident Injuries Act 2017. SIRA (State Insurance Regulatory Authority) oversees these disputes, offering internal review options and pathways to escalate claims. This guide explains your rights, the evidence needed, and the steps to challenge an insurer's decision.
SIRA's Internal Review Process
When an insurer denies or limits your CTP claim, you can request an internal review within 28 days of their decision. This review assesses whether the insurer applied the law correctly, including whether your injuries meet the threshold injury definition under the Motor Accident Guidelines. SIRA will consider medical records, accident reports, and evidence of your injury's impact. If the review upholds the insurer's decision, you may need to escalate the matter further.
Escalating to the Personal Injury Commission
If the internal review doesn't resolve the dispute, you can apply to the Personal Injury Commission (PIC) for a medical dispute review. This process is designed to resolve disagreements about the severity of injuries, such as whether a soft tissue injury qualifies as a threshold injury. The PIC will appoint an independent medical expert to assess your case, focusing on whether your injuries meet the spinal nerve-root qualification outlined in the Motor Accident Guidelines.
Key Evidence for Disputes
To challenge an insurer's decision, you must provide:
- Detailed medical records showing your injury's progression
- Evidence of how the injury affects your daily life
- Accident reports or witness statements supporting your claim
- Proof of any previous medical treatment or rehabilitation
The insurer must demonstrate that your injuries are limited to threshold injuries (e.g., soft tissue injuries without neurological signs) to justify limiting benefits after 52 weeks. If your injury involves spinal nerve-root damage with clinical signs, you may be eligible for ongoing weekly payments.
Time Limits and Practical Steps
You have 28 days from the insurer's decision to request an internal review. If you don't resolve the dispute through this process, you must apply to the PIC within 60 days of the internal review outcome. Delays beyond these deadlines may prevent you from challenging the insurer's decision.
Example Scenario
Consider a case where a claimant disputes their insurer's decision to stop weekly payments after 52 weeks. The insurer argues the injury is a threshold injury, but medical records show the claimant has ongoing back pain and neurological symptoms. The PIC would review whether the injury meets the spinal nerve-root qualification, potentially leading to continued benefits.
When to Seek Legal Advice
While SIRA provides formal dispute pathways, complex cases may require legal assistance. A solicitor can help you:
- Prepare a strong case for review
- Challenge the insurer's interpretation of the Motor Accident Guidelines
- Navigate the PIC's medical dispute process
Next Steps
CTP disputes often depend on the specific facts of your case. To request assistance with your circumstances, complete the quick, no obligation enquiry form. Every claim depends on its own facts.