How Treatment Costs for Ankle Fractures Are Funded 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 you sustained an ankle fracture in a motor vehicle accident in Greater Sydney, your treatment costs may be funded under the NSW Compulsory Third Party (CTP) insurance scheme. This funding is available regardless of who was at fault, provided the injury occurred in a motor accident involving a registered vehicle. The Motor Accident Injuries Act 2017 (MAIA) governs this process and ensures that eligible medical and allied health treatments are covered through the CTP insurer. This includes surgery, physiotherapy, orthotics, and ongoing rehabilitation related to the fracture. Funding is not automatic and depends on the injury being directly caused by the accident and the claim being properly notified and processed.
What SIRA Guidelines Apply to Ankle Fracture Treatment Funding
The State Insurance Regulatory Authority (SIRA) provides detailed guidance on what treatments are covered under the CTP scheme. For ankle fractures, treatment must be clinically necessary and directly related to the injury sustained in the accident. SIRA’s Motor Accident Guidelines outline that treatment must be evidence-based and appropriate to the nature and severity of the injury. This includes initial surgical intervention, post-operative care, and long-term rehabilitation. The insurer is responsible for approving and funding treatment plans, but you must provide medical evidence to support the need for each service. Treatment must be delivered by a registered medical practitioner or allied health professional, and records must be kept to demonstrate the treatment was received and related to the accident.
How the 10% Impairment Threshold Affects Ankle Fracture Claims
Ankle fractures may result in a permanent impairment, which is assessed under the Whole Person Impairment (WPI) rating system. If the WPI is 10% or more, you may be eligible to claim damages for non-economic loss (such as pain and suffering) and future economic loss, subject to the threshold test. The threshold injury provisions in MAIA apply only to claims for damages, not to treatment or weekly payments. If your injury is below 10% WPI, you may still receive treatment and care benefits, and weekly income payments if you are unable to work, but you cannot claim damages for non-economic loss. The 10% threshold is not a test for treatment funding, treatment costs are funded regardless of the WPI, as long as the injury is attributable to the accident and the treatment is clinically justified.
Can Treatment Costs for Ankle Fractures Be Claimed Under Common Law in NSW?
Yes, treatment costs for ankle fractures can be claimed under a common law damages claim, but only if you are pursuing a claim for damages. Common law claims are separate from the CTP scheme and require proof of fault and a higher burden of proof. If you choose to pursue damages, you may recover costs for treatment, past and future loss of income, and non-economic loss. However, common law claims are not a substitute for the CTP scheme, they are an additional pathway that only applies if you meet the threshold injury criteria and choose to proceed. The CTP scheme will still fund treatment and care benefits during the claim process. You cannot claim treatment costs twice, if you are receiving CTP-funded treatment, you cannot claim those same costs again under common law.
Practical Steps and Evidence That Usually Matter
To secure funding for treatment costs, you must act promptly. Seek medical attention immediately after the accident and keep a record of all treatment, including prescriptions, therapy notes, and invoices. Gather evidence such as a police report (if applicable), photographs of the accident scene or vehicle damage, and contact details for any witnesses. Notify your CTP insurer as soon as possible, ideally within 6 months of the accident, to avoid delays. The insurer may require a medical report from your treating practitioner to confirm the injury was caused by the accident. You must also provide proof of income loss if claiming weekly payments. All documentation must be retained and submitted as part of your claim.
Time Limits and Dispute Options
There are time limits for making a CTP claim. You must notify your insurer within 6 months of the accident, and you must start a claim for damages within 3 years of the accident date. These deadlines are strict and cannot be extended unless a court grants an extension. If your insurer refuses to fund a treatment, you may request a review or apply to the Civil and Administrative Tribunal (NCAT) for a determination. Disputes over treatment approval are common, particularly for long-term or specialist care. In such cases, you may need to provide a second medical opinion or seek assistance from a legal practitioner. The SIRA website provides guidance on how to make a claim and resolve disputes, but independent advice is often necessary to navigate complex cases.
When to Seek Advice
Ankle fractures can result in long-term disability, chronic pain, or permanent mobility issues. If your injury is severe, or if you are experiencing delays in treatment approval, it is advisable to seek legal advice. A solicitor experienced in motor accident claims can help you understand your rights, ensure your claim is properly documented, and advocate for funding when disputes arise. The SIRA website offers information on how to find a qualified legal practitioner, but you should not rely solely on online resources when your long-term health and financial wellbeing are at stake.
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