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 disputing a decision by an NSW CTP insurer, understanding SIRA's role and your options is critical. SIRA (State Insurance Regulatory Authority) oversees the Motor Accident Injuries (MAI) scheme, which governs claims for injuries caused by motor vehicles. When disputes arise, SIRA provides a structured process to challenge insurer decisions, but claimants must follow specific steps to ensure their case is reviewed properly.
What SIRA Requires in Disputes
SIRA's role in disputes is to ensure insurers comply with the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. These laws outline the benefits available, the evidence required to support claims, and the procedures for resolving conflicts. For example, if an insurer refuses to pay for treatment or disputes the severity of your injury, you must first exhaust internal review options before escalating to SIRA.
Key requirements include:
- Documenting the dispute: Insurers must provide written reasons for their decisions, and you must keep copies of all correspondence.
- Medical evidence: SIRA requires detailed medical records to assess whether your injury meets the 'threshold injury' criteria or qualifies for long-term benefits.
- Timeliness: Most disputes must be resolved within 52 weeks of the accident, unless there's a valid reason for extension.
Practical Steps for Claimants
When disputing an insurer's decision, follow these steps:
- Review the insurer's response: Check if the insurer has followed the MAI scheme's guidelines, such as the Motor Accident Guidelines, which define what constitutes a 'threshold injury' or 'whole person impairment'.
- Request an internal review: Most insurers have a process to review decisions. This may involve submitting additional evidence or clarifying your claim.
- Escalate to SIRA: If the insurer refuses to reconsider, you can apply to SIRA for a review. This requires a written application explaining your dispute and supporting evidence.
- Seek independent medical advice: If there's a disagreement about your injury's severity, a second opinion from a registered medical practitioner may be necessary.
Time Limits and Dispute Resolution
Disputes must typically be resolved within 52 weeks of the accident, unless the claimant can demonstrate a valid reason for delay. SIRA may also impose time limits for escalating disputes. For example, if an insurer denies a claim, you must usually apply to SIRA within 28 days of receiving the decision.
If your dispute reaches SIRA, the regulator will assess whether the insurer has followed the correct process. However, SIRA does not guarantee a change in the insurer's decision. The outcome depends on whether the insurer's actions breached the MAI scheme's rules.
Hypothetical Example
Imagine you were in a car accident in Ashfield and your insurer refused to cover your physiotherapy treatment. You would first request an internal review, providing your doctor's notes showing the treatment was necessary. If the insurer still denies the claim, you could apply to SIRA, attaching the medical records and explaining why the treatment should be covered. SIRA would then determine if the insurer followed the correct process.
When to Seek Advice
Disputes with insurers can be complex, especially when medical or legal issues are involved. If you're unsure whether your claim meets the criteria for benefits, or if your insurer is not responding to your requests, consider consulting a legal professional. While this article provides general guidance, individual cases depend on specific facts.
Next Steps
CTP disputes require careful documentation and adherence to strict timelines. If you're in Ashfield and facing a disagreement with your insurer, the first step is to ensure you've followed all internal review processes. For further assistance, complete the quick, no obligation enquiry form to request contact about your circumstances.