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 Newcastle or Hunter region and believe your insurer mishandled your treatment or rehabilitation planning for a motor accident claim, you can raise a complaint with the State Insurance Regulatory Authority (SIRA). This article explains the process, evidence needed, and how SIRA evaluates complaints about insurer conduct in NSW.
Filing a SIRA Complaint About Treatment and Rehabilitation Planning
To complain to SIRA about how an insurer is managing your treatment or rehabilitation planning, you must first contact the insurer directly. Most insurers have internal processes to address concerns about care plans, treatment delays, or rehabilitation strategies. If the insurer fails to resolve the issue, you can escalate the matter to SIRA.
SIRA evaluates complaints by assessing whether the insurer has acted in accordance with the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines. This includes checking if the insurer has followed the agreed treatment plan, provided timely access to medical professionals, or adequately funded rehabilitation services.
Evidence to Support a SIRA Complaint
When lodging a complaint, you must provide evidence that the insurer’s actions fell short of the agreed care plan. Key documents include:
- Medical records showing delays or unmet treatment goals
- Correspondence with the insurer about rehabilitation planning
- Evidence of poor communication between the insurer and your treating medical team
- Records of denied or delayed access to recommended therapies
For example, if your insurer refused to fund a physiotherapy plan agreed with your doctor, this could form the basis of a complaint. Always keep copies of all communications with the insurer.
How SIRA Evaluates Complaints About Insurer Conduct
SIRA reviews complaints by examining the insurer’s compliance with the Motor Accident Guidelines. This includes assessing whether the insurer has:
- Approved necessary medical treatments and therapies
- Coordinated with your healthcare providers
- Paid for agreed rehabilitation services within the 52-week statutory benefit period
If SIRA finds the insurer has breached its obligations, it may issue a formal notice requiring the insurer to correct the issue. In serious cases, SIRA can impose financial penalties on the insurer.
Time Limits for Lodging a SIRA Complaint
There is no specific time limit for lodging a complaint with SIRA, but it is important to act promptly. Delays may reduce the chances of resolving the issue, as insurers often have limited records of past decisions. If you believe your insurer has not followed the agreed care plan, contact SIRA within a reasonable timeframe, ideally within 6 months of the incident.
When to Seek Legal Advice
If your complaint involves complex issues such as disputes over the threshold injury definition, weekly income payments, or disputes about the 52-week statutory benefit period, you may need to consult a solicitor. Legal advice can help you understand your rights under the Motor Accident Injuries Act 2017 and ensure your complaint is properly prepared.
Next Steps
If you believe your insurer has not followed the agreed treatment and rehabilitation plan, start by contacting the insurer directly. If the issue remains unresolved, you can escalate the matter to SIRA. Always keep detailed records of all communications and medical evidence to support your complaint.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.