Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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 involved in a motor accident in Greater Sydney and believe an insurer has mishandled your claim, understanding how insurers assess liability and how SIRA handles complaints is critical. This article explains the legal framework behind CTP claims, how insurers evaluate fault, and the process for lodging a complaint with NSW’s Motor Accident Claims Authority (SIRA). It also outlines practical steps to challenge an insurer’s liability assessment.
How Insurers Assess Liability in CTP Claims
Under the Motor Accident Injuries Act 2017, insurers must determine liability based on fault, not the severity of injuries. When assessing liability, insurers consider:
- Fault: Whether the other driver breached a duty of care (e.g., speeding, running a stop sign).
- Evidence: Police reports, witness statements, medical records, and accident reconstruction data.
- Legal standards: Whether the accident meets the threshold injury criteria under the Motor Accident Guidelines.
Insurers may also evaluate whether the claimant’s injuries align with the accident’s circumstances. For example, if a driver claims soft-tissue injuries but medical records show no neurological signs, the insurer might dispute liability.
SIRA’s Role in Handling Complaints
SIRA oversees the CTP scheme and handles complaints about insurers’ conduct. To lodge a complaint:
- Gather evidence: Collect documents like accident reports, correspondence with the insurer, and medical records.
- Submit a complaint: Use SIRA’s online form or contact them directly. Complaints must be made within 12 months of the accident or when the issue arose.
- SIRA’s review: SIRA will assess whether the insurer acted unreasonably or breached its obligations under the CTP scheme.
SIRA cannot overturn an insurer’s liability decision but can investigate if the insurer failed to follow proper procedures or acted in bad faith.
Key Considerations When Disputing Liability
If you believe an insurer’s liability assessment is incorrect, consider these factors:
- Fault determination: Ensure the insurer’s fault analysis matches the accident’s circumstances. For example, if the insurer blames you for the accident but there’s no evidence of your fault, this could be a dispute point.
- Threshold injury criteria: If your injuries fall below the threshold (e.g., no spinal nerve-root injury), the insurer may limit benefits after 52 weeks. SIRA will assess whether the injury meets the guidelines.
- Time limits: Claims must be made within 12 months of the accident. Delays can affect your ability to challenge an insurer’s decision.
A practical example: A driver involved in a collision with a cyclist claims soft-tissue injuries. The insurer assesses liability based on fault but denies benefits, arguing the injuries are not threshold injuries. SIRA would review whether the medical evidence supports the claimant’s injuries and whether the insurer followed the guidelines.
When to Seek Legal Advice
SIRA’s role is regulatory, not adversarial. If your complaint is rejected or you’re unsure about your insurer’s assessment, consult a solicitor. Legal advice can help you:
- Challenge the insurer’s interpretation of fault or injury severity.
- Navigate complex claims involving multiple parties or overlapping schemes (e.g., workers’ compensation).
- Understand your rights under the CTP scheme and the Motor Accident Injuries Act 2017.
Next Steps
CTP claims and insurer conduct can be complex, especially when disputes arise. The process for lodging complaints with SIRA and the legal standards insurers use to assess liability depend on the accident’s circumstances and evidence. To request contact about your circumstances, complete the quick, no obligation enquiry form.