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 incorrectly determined your eligibility for the NSW Compulsory Third Party (CTP) scheme, you can raise a complaint with the State Insurance Regulatory Authority (SIRA). This article explains the process for lodging a complaint, the evidence required, and how SIRA assesses insurer eligibility under the Motor Accident Injuries Act 2017.
What is the process for lodging a complaint with SIRA?
SIRA oversees the NSW CTP scheme and handles complaints about insurers’ conduct, including eligibility decisions. To file a complaint, you must:
- Submit a written complaint to SIRA via their official website or postal address.
- Include details of the insurer’s decision, such as a letter or email confirming your claim was rejected.
- Provide evidence supporting your case, such as medical records, accident reports, or witness statements.
SIRA will review your complaint and may request additional information. If the insurer’s decision is found to be incorrect, SIRA can issue a binding ruling to correct the eligibility determination.
What evidence supports a SIRA complaint about insurer eligibility?
To challenge an insurer’s eligibility decision, you must demonstrate that the insurer’s assessment was legally or factually flawed. Key evidence includes:
- A copy of the insurer’s rejection letter or eligibility decision.
- Medical records confirming your injury meets the scheme’s criteria (e.g., threshold injury or whole person impairment rating).
- Police reports, witness statements, or CCTV footage showing the accident.
- Documentation of your financial impact, such as lost wages or medical bills.
SIRA will evaluate whether the insurer applied the correct legal standards under the Motor Accident Injuries Act 2017, including the 52-week statutory benefit rules for threshold injuries.
How does SIRA determine insurer eligibility?
SIRA assesses whether insurers have complied with the CTP scheme’s rules, including:
- Whether the insurer correctly identified the accident as a motor vehicle incident.
- Whether the claimant meets the scheme’s eligibility criteria (e.g., residency requirements or injury thresholds).
- Whether the insurer applied the correct legal definitions, such as 'threshold injury' under the Motor Accident Guidelines.
SIRA does not determine the merits of a claim itself but ensures insurers follow the statutory framework. If an insurer’s decision is found to be incorrect, SIRA can direct the insurer to reconsider your claim.
Practical steps for Auburn residents
If you’re in Auburn and believe your insurer has wrongly denied your CTP claim, take these steps:
- Gather all documents related to your claim, including the insurer’s rejection letter.
- Visit SIRA’s website to download the complaint form or contact them directly.
- Submit your complaint within the time limits outlined in the Motor Accident Injuries Regulation 2017.
- Seek legal advice if the insurer refuses to reconsider your claim.
When to seek independent legal advice
While SIRA provides a formal complaints process, complex cases may require legal assistance. A solicitor can help you:
- Challenge the insurer’s interpretation of the law.
- Navigate disputes over medical evidence or injury thresholds.
- Ensure all procedural deadlines are met.
Next steps
CTP eligibility decisions can depend on the accident date, injury type, and insurer conduct. If you’re unsure whether your claim meets the scheme’s criteria, complete the quick, no obligation enquiry form to request contact about your circumstances.