If you believe your eligibility for NSW CTP scheme benefits has been wrongly determined, you can dispute the decision by lodging a complaint with the State Insurance Regulatory Authority (SIRA). This guide explains how to challenge a CTP eligibility decision, what evidence to prepare, and time limits to consider.
How SIRA Determines CTP Scheme Eligibility
Under the Motor Accident Injuries Act 2017, your eligibility for CTP benefits depends on whether your injury meets the 'threshold injury' definition. This includes injuries like whiplash, soft tissue damage, or fractures that result in a whole person impairment (WPI) of 10% or more. SIRA assesses claims based on medical evidence, including clinical reports and imaging.
If your injury does not meet the threshold, you may still qualify for limited benefits under the 52-week statutory scheme. For example, if your only injuries are soft tissue damage without WPI, you may receive weekly income payments and treatment benefits for up to 52 weeks. However, if your injury falls below this threshold, your claim may be denied.
Steps to Lodge a SIRA Complaint
To dispute an eligibility decision, you must first contact the insurer that issued your CTP claim. If the insurer refuses to reconsider, you can submit a written complaint to SIRA. Include:
- A copy of your claim form and any correspondence with the insurer
- Medical records confirming your injury meets the threshold
- Evidence of your financial impact, such as income loss or medical bills
- A clear explanation of why you believe the decision was incorrect
SIRA will review your complaint and may request additional information. If your case involves a dispute over the threshold injury definition, you may need to provide expert medical opinion to support your case.
Time Limits for Challenging CTP Decisions
You have 52 weeks from the date of your accident to claim benefits under the statutory scheme. If your injury does not meet the threshold, you may still challenge the decision within this period. However, if your claim is denied after 52 weeks, you may need to seek legal advice to explore options for extending your claim.
When to Seek Legal Advice
If your injury involves complex medical issues, such as spinal nerve-root damage or radiculopathy, you may need a specialist to assess whether your condition meets the threshold. SIRA's guidelines specify that radiculopathy requires clinical signs like sensory loss or reflex changes to qualify as a threshold injury.
A hypothetical example: Sarah sustained a soft tissue injury in a car accident in Bega. Her medical records show no whole person impairment, so she is denied benefits. She lodges a complaint with SIRA, arguing her injury meets the threshold. SIRA reviews her records and confirms her claim does not qualify, so she must seek alternative support.
Next Steps
CTP scheme eligibility depends on the date of your accident, the nature of your injury, and the evidence you provide. If you are unsure whether your claim meets the threshold, complete the quick, no obligation enquiry form to request contact about your circumstances.