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're in the Illawarra or South Coast regions of New South Wales and disagree with an insurer's decision on your Compulsory Third Party (CTP) claim, you may be able to challenge their ruling through the State Insurance Regulatory Authority (SIRA). This article explains how to dispute insurer decisions, what SIRA considers during reviews, and the practical steps to take.
How to Challenge an Insurer's CTP Claim Decision
To dispute an insurer's decision, you must first contact SIRA directly. SIRA oversees the CTP scheme and ensures insurers comply with the Motor Accident Injuries Act 2017. You can raise concerns about decisions such as denied claims, reduced benefits, or incorrect interpretations of your injury.
The first step is to gather evidence supporting your case. This includes medical records, accident reports, witness statements, and any correspondence with the insurer. SIRA will review your complaint and may request additional information or clarification from the insurer.
What SIRA Considers When Reviewing Claims
SIRA evaluates complaints based on whether the insurer followed the correct legal framework. This includes checking if the insurer applied the Motor Accident Guidelines accurately and whether their decision aligns with the CTP scheme rules.
For example, if an insurer denies a claim for a 'threshold injury', an injury meeting the minimum severity criteria under the Motor Accident Guidelines, SIRA will assess whether the insurer correctly interpreted the guidelines. SIRA also considers whether the insurer provided a clear explanation for their decision.
Practical Steps to File a SIRA Complaint
- Contact SIRA directly via their Illawarra or South Coast office. You can find contact details on the SIRA website.
- Submit your complaint in writing, clearly outlining the insurer's decision and your disagreement.
- Provide supporting evidence such as medical reports, accident details, and any correspondence with the insurer.
- Wait for SIRA's review. SIRA will notify you of their findings and may mediate between you and the insurer.
Time Limits and When to Seek Advice
There is no strict time limit to challenge an insurer's decision, but it's important to act promptly. Delays may reduce the chances of a successful review, especially if new evidence emerges. If your claim involves complex issues like long-term injuries or disputes over weekly benefits, consider seeking legal advice early.
Example: Disputing a Threshold Injury Decision
Suppose an insurer denies your claim for a soft-tissue injury, arguing it doesn't meet the 'threshold injury' criteria. You may challenge this by providing medical evidence showing neurological signs, such as a spinal nerve-root injury, as defined in the Motor Accident Guidelines. SIRA will assess whether the insurer correctly applied the guidelines.
Next Steps
If you're unsure whether your case meets SIRA's criteria or need help preparing your complaint, contact LegalAdvice.com.au. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.