If you believe an insurer has wrongly denied your eligibility for NSW's Compulsory Third Party (CTP) scheme, you can dispute their decision by contacting the State Insurance Regulatory Authority (SIRA). This article explains the legal basis for scheme eligibility, the evidence needed to challenge an insurer's decision, and the process for escalating complaints to SIRA.
Understanding CTP Scheme Eligibility
Under the Motor Accident Injuries Act 2017, the CTP scheme provides compensation for injuries caused by motor vehicle accidents. To qualify, you must have been injured in an accident involving a motor vehicle registered in NSW, and the injury must meet the scheme's definition of a 'threshold injury' or higher. SIRA administers the scheme and has the authority to review disputes about whether an injury falls within the scheme's coverage.
Insurers must determine whether your injury meets the scheme's criteria, but they can make errors. For example, an insurer might wrongly exclude a soft tissue injury if it doesn't meet the specific neurological signs outlined in the Motor Accident Guidelines. If you believe this has happened, you can challenge the decision.
What Evidence Supports a Scheme Eligibility Complaint?
To dispute an insurer's decision, you'll need to provide evidence that your injury meets the CTP scheme's criteria. Key documents include:
- Medical records confirming your injury (e.g., a diagnosis of a threshold injury or higher)
- Accident reports showing the incident involved a NSW-registered motor vehicle
- Witness statements or photographs of the accident scene
- Correspondence with the insurer detailing their refusal to cover your claim
If your injury is a 'threshold injury', you must demonstrate it meets the spinal nerve-root qualification: a spinal nerve-root injury producing neurological signs other than radiculopathy may still qualify, while radiculopathy requires specific clinical signs.
How to Escalate a Complaint to SIRA
SIRA handles complaints about insurer decisions through its Motor Accident Claims team. You can submit a complaint by:
- Visiting the SIRA website and completing the online complaint form
- Calling SIRA directly to request a written complaint form
- Submitting a written complaint by post to the SIRA office in Armidale
When you file a complaint, SIRA will review your case and may request additional information from you or the insurer. They must respond within 21 days of receiving your complaint, though complex cases may take longer.
Time Limits and Dispute Resolution
You must file a complaint with SIRA within 28 days of the insurer's decision, unless you have a valid reason for the delay. If your complaint is rejected, you may need to escalate the matter to the NSW Civil and Administrative Tribunal (NCAT) for further review.
When to Seek Legal Advice
While SIRA provides a formal complaints process, it's important to seek legal advice if:
- The insurer has refused to cover your claim despite your injury meeting the scheme's criteria
- You're unsure whether your injury qualifies as a 'threshold injury'
- You need assistance preparing your complaint to SIRA
A solicitor can help you understand your rights under the Motor Accident Injuries Act 2017 and ensure your complaint includes all necessary evidence.
Practical Example
Imagine you were in a car accident in Armidale and suffered a soft tissue injury. The insurer denied your claim, arguing your injury doesn't meet the scheme's threshold. You could challenge this by providing your doctor's notes showing neurological signs of a spinal nerve-root injury. SIRA would then review your case and determine whether your injury qualifies for compensation.
Next Steps
CTP scheme eligibility depends on the specific facts of your case. To request contact about your circumstances, complete the quick, no obligation enquiry form.