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 wrongly denied or limited your eligibility for NSW CTP scheme benefits, you can challenge their decision by lodging a complaint with the State Insurance Regulatory Authority (SIRA). This article explains the process, required evidence and legal basis for disputing an insurer's assessment of your claim under the Motor Accident Injuries Act 2017.
What is the CTP Scheme Eligibility Process?
Under the NSW CTP scheme, injured road users are entitled to specific benefits if their injury meets the scheme's criteria. The Motor Accident Injuries Act 2017 defines eligibility based on injury type, not fault. Insurers must assess claims against the scheme's rules, including the threshold injury provisions. If an insurer denies benefits, you may dispute their decision by showing:
- Your injury meets the scheme's definition of a threshold injury or higher
- The insurer applied incorrect legal standards
- The assessment ignored relevant evidence
How to Lodge a SIRA Complaint About Eligibility
To challenge an insurer's decision, you must submit a written complaint to SIRA within 28 days of receiving their response. The complaint must:
- Clearly state the issue with the insurer's assessment
- Include your claim number and details of the denied benefits
- Attach evidence supporting your eligibility, such as:
- Medical records confirming your injury
- Accident reports or witness statements
- Proof of income if seeking weekly payments
- Correspondence with the insurer
SIRA will review your complaint and may request additional information. They must respond within 28 days of receiving your submission.
What Evidence Matters for Scheme Eligibility?
When disputing an insurer's eligibility decision, focus on:
- Medical evidence: SIRA relies on the Motor Accident Guidelines to assess injury severity. Ensure your medical records show:
- A spinal nerve-root injury with neurological signs
- Radiculopathy with specified clinical signs
- A whole person impairment rating if applicable
- Accident details: Provide evidence of the incident's circumstances, including:
- Vehicle registration numbers
- Witness contact information
- Police reports or traffic camera footage
- Insurer's assessment: Include copies of the insurer's decision letter and any correspondence where they denied benefits.
Time Limits and Dispute Options
You must lodge a complaint with SIRA within 28 days of the insurer's adverse decision. If SIRA upholds the insurer's decision, you may:
- Request a review by the NSW Civil and Administrative Tribunal (NCAT) within 28 days of SIRA's response
- Seek independent legal advice if you believe the insurer applied incorrect legal standards
When to Seek Legal Advice
Consult a solicitor if:
- The insurer's decision ignores the scheme's threshold injury rules
- You have a pre-existing injury that may affect eligibility
- The insurer disputes your medical evidence
- You need help drafting a complaint to SIRA
Example Scenario
Consider a pedestrian injured in a car accident. The insurer denies weekly payments, claiming the injury is below the threshold. You can challenge this by:
- Providing medical evidence showing a spinal nerve-root injury with neurological signs
- Demonstrating the injury meets the Motor Accident Guidelines' threshold criteria
- Showing the insurer applied incorrect legal standards when assessing your claim
Next Steps
CTP scheme eligibility depends on the date of your accident, injury type and the insurer's assessment. To request contact about your circumstances, complete the quick, no obligation enquiry form.