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 believe an insurer has failed to properly document your injury for a NSW Compulsory Third Party (CTP) claim, you may need to raise a complaint with the State Insurance Regulatory Authority (SIRA). This article explains the evidence required to support such a complaint, how SIRA evaluates injury documentation, and practical steps to prepare a compliant claim.
What Evidence is Needed for a SIRA Complaint About Injury Documentation?
To challenge an insurer's handling of injury documentation, you must demonstrate that the documentation does not meet the legal standards for CTP claims. Key evidence includes:
- Medical records showing the injury's nature, treatment, and recovery timeline
- Accident reports from police or witnesses detailing the incident
- Photographs of the scene, vehicle damage, and injuries
- Witness statements confirming the accident and injury
- Correspondence with the insurer showing delays or refusal to acknowledge documentation
- SIRA's own guidelines on acceptable documentation (refer to SIRA's claims page)
SIRA requires documentation to prove the injury meets the legal definition of a 'threshold injury' under the Motor Accident Injuries Act 2017. This includes showing the injury caused a 'loss of function' or 'pain and suffering' that meets the Motor Accident Guidelines.
How SIRA Evaluates Injury Documentation
SIRA assesses whether the documentation supports a claim for:
- Statutory benefits (weekly payments, treatment costs) under the CTP scheme
- Damages for pain, loss of income, or other impacts
Insurers must provide evidence that the injury is 'not a minor injury' under the guidelines. If documentation is incomplete or inconsistent, SIRA may require the insurer to revise its assessment. For example, if a claimant's medical records lack evidence of a 'loss of function' but the insurer pays weekly benefits, this could indicate a documentation error.
Practical Steps to Prepare a SIRA Complaint
- Gather all relevant documents from your claim file, including medical reports, accident reports, and correspondence with the insurer.
- Identify gaps in the documentation. For instance, if the insurer refuses to acknowledge a doctor's note about your injury, this could be a key point.
- Review SIRA's guidelines on what constitutes acceptable evidence. If the insurer's documentation fails to meet these standards, you have grounds for a complaint.
- Submit a formal complaint to SIRA using their online portal or by mail. Include copies of all relevant documents to support your case.
Example: When Documentation Falls Short
Consider a scenario where a claimant sustains a soft-tissue injury (e.g., a whiplash) but the insurer refuses to pay weekly benefits. If the medical records lack specific details about the injury's impact (e.g., no mention of 'loss of function'), the insurer may be underpaying. In such cases, SIRA may require the insurer to revise its assessment or provide a justification for denying benefits.
Time Limits and When to Seek Advice
You have five years from the date of the accident to raise a complaint with SIRA. However, it's crucial to act promptly, as delays can weaken your case. If you're unsure whether the documentation meets legal standards, consult a legal professional. SIRA's role is to ensure insurers comply with the law, but they cannot provide legal advice on individual claims.
Next Steps
If you believe an insurer has mishandled your injury documentation, start by compiling the evidence outlined above. SIRA's complaint process is designed to address such issues, but it's important to act before time limits expire. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.