How Insurers Assess Ankle Fracture Claims in NSW
An ankle fracture sustained in a motor vehicle accident in New South Wales is assessed under the Motor Accident Injuries Act 2017 (MAIA), which governs the Compulsory Third Party (CTP) insurance scheme. Insurers make decisions based on medical evidence, the legal definition of a threshold injury, and whether the injury has caused lasting impairment. In Greater Sydney and across NSW, decisions must follow the Motor Accident Guidelines and SIRA’s administrative processes, not personal judgment. The insurer will review your medical records, treatment history, and any whole person impairment (WPI) assessment to determine eligibility for treatment and care benefits, weekly income payments, and, if applicable, damages.
Legal Requirements for Compensation
Under the MAIA, a threshold injury includes a soft tissue injury, a psychological or psychiatric injury not classified as a recognised illness, and injuries that result in a WPI of 10% or more. An ankle fracture may qualify as a threshold injury if it causes ongoing pain, limited mobility, or functional impairment, even after bone healing. The presence of neurological signs such as sensory loss or muscle weakness in the foot or leg, confirmed by imaging and clinical testing, may support a claim for damages.
If your only injuries are threshold injuries, weekly benefits and treatment and care benefits are generally limited to 52 weeks from the date of the accident. This restriction applies under sections 3.11 and 3.28 of the MAIA. After 52 weeks, benefits cease unless the injury has not resolved and you meet the criteria for damages. To claim damages, you must demonstrate that the injury has not resolved within 52 weeks and that it continues to impact your daily life, work, or capacity for enjoyment.
What Insurers Consider in Their Decision
Insurers assess claims using several factors. They review your medical records, including radiology reports, surgical notes, physiotherapy progress, and assessments by your treating medical practitioner. They determine whether the fracture was caused by the motor accident and not by a pre-existing condition or a separate incident. They also assess the impact on your ability to work, perform daily tasks, and participate in social and recreational activities.
A key factor is whether you have reached medical stability, meaning your recovery has plateaued and further improvement is unlikely. This is critical because benefits such as weekly payments and treatment and care benefits are generally limited to 52 weeks if your only injuries are threshold injuries. If your ankle fracture results in a WPI of 10% or more and you have not recovered within 52 weeks, you may be eligible to claim damages for pain and suffering, loss of enjoyment of life, and future care needs.
Evidence to Support Your Claim
To strengthen your claim, preserve and provide the following evidence:
- Medical reports from your treating doctor, orthopaedic surgeon, and any specialist involved in your care.
- Imaging results such as X-rays, MRIs, or CT scans showing the fracture and any complications.
- Records of treatment, including surgery, rehabilitation, and use of mobility aids.
- A whole person impairment (WPI) assessment conducted by a qualified medical assessor under the MAIA.
- A statement of your daily activities before and after the accident, including work, household tasks, and social participation.
- Documentation of any loss of income, including payslips, tax returns, and a letter from your employer.
If the insurer disputes your WPI or the extent of your functional impairment, you have the right to request a review under SIRA’s dispute resolution process. You may also seek an independent medical assessment to challenge the insurer’s findings.
Formal Processes for Challenging a Decision
There is a strict time limit to make a claim under the CTP scheme. You must notify your insurer within 3 months of the accident, or within 3 months of becoming aware of the injury, whichever is later. Failure to notify within this period may prevent you from claiming benefits, unless you can demonstrate a reasonable excuse.
If your claim is denied or you disagree with the insurer’s decision on benefits, you can request a review. SIRA provides a formal dispute resolution process, which includes mediation and, if necessary, a review by the SIRA Review Panel. You may also apply to the NSW Civil and Administrative Tribunal (NCAT) for a determination on your claim. These processes are designed to ensure decisions are made fairly and in accordance with the law.
Practical Example: A Claim in Greater Sydney
A 38-year-old office worker in Sydney sustained a displaced ankle fracture in a rear-end collision on the M4 motorway in October 2026. The injury required surgery and six months of rehabilitation. The medical assessor determined a WPI of 14% due to chronic pain, limited ankle mobility, and reduced capacity to walk long distances. The insurer initially refused damages, arguing the injury had resolved within 52 weeks. However, because the injury was still affecting daily life and work capacity, and because the WPI exceeded 10%, the claimant successfully challenged the decision through SIRA’s dispute process and was awarded damages for pain and suffering and future care needs.
Next Steps
Every claim depends on its own facts. The outcome of an ankle fracture claim in NSW depends on the severity of the injury, the quality and completeness of medical evidence, and whether the injury meets the legal threshold for damages. Insurer decisions are not final and can be challenged through formal processes. If you believe your claim has been unfairly assessed, you should seek independent advice.
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