Understanding Insurer Decisions in NSW CTP Claims
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 an insurer has denied or limited your motor accident compensation claim in Greater Sydney, you may have grounds to raise a complaint with the State Insurance Regulatory Authority (SIRA). Insurers make decisions based on the Motor Accident Injuries Act 2017 (MAIA), which governs all CTP claims in NSW. These decisions commonly relate to eligibility for weekly income payments, treatment and care benefits, or damages for injury. The insurer’s decision may be based on medical evidence, the nature of the injury, or whether the injury meets the threshold for damages under the Act.
Common Reasons for Insurer Decisions
Insurers typically base decisions on one or more of the following factors under the MAIA:
- Whether the injury qualifies as a threshold injury, which limits entitlement to damages
- Whether the injury is considered to have resulted from the motor accident
- Whether treatment and care benefits are still required or appropriate
- Whether weekly income payments are justified based on loss of earnings
For example, if a claimant reports neck pain and numbness following a rear-end collision, the insurer may assess whether clinical signs of a spinal nerve-root injury are present. If signs are not confirmed, the injury may not meet the threshold for damages, leading to a decision to limit benefits.
How to Challenge an Insurer’s Decision
If you disagree with an insurer’s decision, you can raise a formal complaint with SIRA. SIRA is the independent body responsible for regulating CTP insurers and ensuring decisions are made under the MAIA. You must first attempt to resolve the matter directly with the insurer. If unresolved, you may submit a complaint to SIRA using the online form on the SIRA website.
SIRA will review the insurer’s decision, including all supporting evidence such as medical reports, accident details, and correspondence. SIRA may contact you to request further information. The process is not a court hearing, but SIRA has the authority to direct the insurer to reconsider or change its decision.
Key Steps to Take
To strengthen your case when challenging an insurer’s decision, gather and preserve the following:
- Medical records and reports from your treating practitioner
- A copy of the insurer’s written decision, including any reasons provided
- Photographs of the accident scene, vehicle damage, or injury symptoms
- Witness contact details and statements
- Records of lost income, such as payslips or employer letters
- Correspondence with the insurer, including emails and letters
Keep all documents in a folder, either physical or digital. Do not alter or destroy any evidence.
Time Limits and Procedural Requirements
There is no fixed time limit for making a SIRA complaint, but delays may affect the strength of your case. SIRA encourages prompt action, particularly where medical treatment, income loss, or evidence is time-sensitive. If you are seeking damages, you must generally have made a claim within three years of the accident date, as required by the Limitations Act 1969.
If you have already received a decision on a claim, you should not wait more than 12 months to raise a SIRA complaint, as delays may hinder SIRA’s ability to investigate fully.
When to Seek Independent Advice
SIRA is not a legal service. It does not provide legal advice or represent claimants. If you are unsure about your rights, the evidence needed, or how to present your case, it is advisable to seek independent legal advice. A solicitor experienced in motor accident claims can help you understand whether the insurer’s decision was correct under the MAIA, and whether a SIRA complaint is appropriate.
For example, if an insurer denied weekly payments because of a perceived lack of income loss, but you have a medical certificate confirming an inability to work, a solicitor can help you assess whether the insurer’s decision was reasonable and whether to proceed with a complaint.
SIRA’s Role and Outcomes
SIRA does not determine compensation amounts. It reviews whether the insurer’s decision was made under the correct legal framework and whether it was reasonable given the evidence. SIRA may:
- Request the insurer to reconsider its decision
- Require the insurer to provide additional information
- Direct the insurer to pay a benefit that was previously denied
SIRA’s decision is binding on the insurer. If the insurer does not comply, SIRA may take further regulatory action.
Practical Example
A pedestrian in Sydney’s inner west was struck by a car at a crosswalk in June 2024. The insurer initially approved treatment and care benefits but later refused weekly income payments, stating the claimant had not provided sufficient evidence of lost earnings. The claimant submitted payslips and a letter from their employer confirming a 30% reduction in hours. After a SIRA complaint, SIRA directed the insurer to reconsider the claim. The insurer subsequently approved weekly payments.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.