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 NSW Compulsory Third Party (CTP) insurer has made an incorrect decision about your motor accident claim, you can formally challenge their decision through the State Insurance Regulatory Authority (SIRA). This article explains how to lodge a complaint with SIRA, what evidence is needed, and how SIRA evaluates insurer decisions compared to official claim guidelines.
Understanding SIRA's Role in CTP Claims
SIRA oversees the NSW CTP scheme, ensuring insurers comply with the Motor Accident Injuries Act 2017 and Motor Accident Guidelines. When an insurer denies or limits benefits, SIRA assesses whether their decision aligns with the scheme's rules. For example, if an insurer rejects a claim for soft-tissue injuries without meeting the spinal nerve-root criteria in the guidelines, you may have grounds for a complaint.
Practical Steps to Lodge a SIRA Complaint
To file a complaint, follow these steps:
- Contact the insurer first - Request a written explanation of their decision, referencing the specific sections of the Motor Accident Guidelines.
- Gather evidence - Collect documents like medical reports, accident records, and correspondence with the insurer. Ensure your evidence addresses whether the insurer applied the guidelines correctly.
- Submit a written complaint - Use SIRA's online form or mail a letter to SIRA detailing the issue. Include the insurer's name, your claim reference number, and specific concerns about their decision.
What Evidence Matters Most to SIRA?
SIRA evaluates complaints based on whether insurers followed the scheme's rules. Key evidence includes:
- Medical evidence - Reports confirming injuries meet the threshold injury definition (e.g., spinal nerve-root injuries with neurological signs).
- Insurer's decision letter - Shows how the insurer interpreted the guidelines.
- Comparison to Motor Accident Guidelines - Demonstrates if the insurer applied the rules consistently with SIRA's interpretations.
How SIRA Assesses Complaints
SIRA reviews complaints by checking if insurers:
- Applied the correct injury definitions (e.g., threshold injuries vs. whole person impairment).
- Considered all relevant evidence, including medical opinions.
- Complied with statutory deadlines, such as the 52-week limit for weekly benefits after threshold injuries.
For example, if an insurer denied weekly benefits after 52 weeks without explaining how the injury no longer meets the threshold criteria, SIRA may find the decision inconsistent with the Motor Accident Injuries Act 2017 s 4.4.
When to Seek Legal Advice
While SIRA handles complaints about insurer decisions, complex cases may require a solicitor. Consider consulting a lawyer if:
- The insurer disputes your claim's validity.
- You need help interpreting SIRA's responses.
- You face a dispute over long-term benefits or lifetime care.
Time Limits and Next Steps
You must lodge a complaint with SIRA within 28 days of receiving the insurer's decision. If SIRA's response is unsatisfactory, you may request a review or escalate the matter through the NSW Civil and Administrative Tribunal (NCAT).
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.