How NSW CTP Insurers Assess Liability for Ankle Fractures
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).
In New South Wales, insurers assess liability for ankle fractures in car accidents by evaluating the accident's circumstances, not just the injury type. Under the Motor Accident Injuries Act 2017, claims are governed by the Compulsory Third Party (CTP) scheme, which requires insurers to pay benefits for injuries caused by motor vehicle accidents. Ankle fractures, like other soft-tissue injuries, fall under this framework, but insurers must determine if the injury meets the threshold injury criteria outlined in the Motor Accident Guidelines.
Insurers typically consider factors such as the nature of the collision, vehicle involvement, and medical evidence to establish liability. For example, if the accident involved a collision with a car, bus, or truck, the insurer must assess whether the injury resulted from the accident's forces. SIRA (State Insurance Regulatory Authority) provides guidelines that insurers follow, emphasizing that ankle fractures are treated as threshold injuries unless they meet the criteria for a whole-person impairment rating.
Evidence Required for Ankle Fracture Claims
To support a CTP claim for an ankle fracture, injured individuals must provide:
- Medical records confirming the fracture and its connection to the accident.
- Accident reports from the police or insurance company.
- Witness statements or photographs of the scene.
- Evidence of treatment (e.g., X-rays, scans, physiotherapy records).
SIRA’s guidelines stress that insurers must consider the full clinical picture, including whether the fracture required surgery or prolonged recovery. For instance, a simple ankle fracture with minimal treatment may still qualify as a threshold injury, while a complex fracture requiring surgery might be assessed under the whole-person impairment framework.
SIRA’s Approach to Ankle Fractures vs. Other Injuries
SIRA’s approach to ankle fractures differs from other injuries because they are classified as soft-tissue injuries under the Motor Accident Guidelines. This means they are generally limited to 52 weeks of weekly benefits unless the injury results in long-term impairment. For example, if an ankle fracture leads to chronic pain requiring ongoing treatment, the claimant may need to pursue a whole-person impairment assessment to qualify for extended benefits.
Insurers must also consider contributory fault, if the injured person contributed to the accident, their claim may be reduced. However, blameless accidents (where the injured party had no fault) are fully covered under the CTP scheme.
Time Limits and Dispute Options
CTP claims in NSW have strict time limits. Most benefits are limited to 52 weeks after the accident, unless the injury is classified as a threshold injury or the claimant can prove long-term impairment. If an insurer denies a claim, the injured person may need to challenge the decision through the NSW Civil and Administrative Tribunal (NCAT) or seek legal advice.
When to Seek Legal Advice
Legal assistance is recommended if:
- The insurer denies the claim without clear reasoning.
- The injury requires a whole-person impairment assessment.
- The claimant is unsure if their ankle fracture qualifies as a threshold injury.
- The accident occurred in a high-risk location (e.g., a car park or intersection) where liability is disputed.
Practical Example
Consider a driver in Ashfield who suffered an ankle fracture after a collision with a car. The insurer would assess liability by reviewing:
- Police reports confirming the accident.
- Medical records showing the fracture was caused by the collision.
- Evidence that the injury required treatment (e.g., a cast or physiotherapy).
If the insurer denies the claim, the injured person may need to dispute the decision using SIRA’s guidelines or seek legal advice to challenge the assessment.
Next Steps
CTP entitlements depend on the accident date, injury type, and claim history. To request contact about your circumstances, complete the quick, no obligation enquiry form.