How SIRA Determines Eligibility for Attendant Care Services 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).
Under NSW's Compulsory Third Party (CTP) scheme, SIRA assesses whether a claimant is entitled to attendant care services based on medical necessity and documented evidence. This guide explains the rules SIRA applies to determine eligibility and compensation for care and supervision needs following a motor accident.
Key Rules SIRA Uses for Attendant Care Claims
SIRA evaluates claims using the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines. To qualify for attendant care services, a claimant must demonstrate:
- Medical necessity: A medical practitioner must confirm the injury requires assistance with daily activities like dressing, eating, or mobility. SIRA considers clinical records, care plans, and reports from treating doctors.
- Threshold injury criteria: The injury must meet the definition of a 'threshold injury' under the Motor Accident Guidelines. This includes injuries requiring treatment by a medical practitioner and resulting in at least two weeks of absence from work or study.
- No contributory fault: The claimant must not have contributed to the accident. SIRA assesses fault based on police reports, witness statements, and evidence from the accident scene.
Evidence SIRA Requires to Support a Claim
To prove the need for attendant care, claimants must provide:
- Medical records showing the injury's impact on daily living
- A care plan from a registered nurse or physiotherapist
- Evidence of the injury's severity, such as imaging reports or specialist opinions
- Documentation of the claimant's inability to perform essential tasks independently
SIRA may request additional evidence if the claimant's need for care appears inconsistent with the provided documentation.
Time Limits and Dispute Resolution
Claimants must notify SIRA of their intention to claim attendant care services within 6 months of the accident. If a claim is disputed, SIRA will review the evidence and may request a medical assessment. Claimants can also seek independent legal advice to challenge a decision.
Example of SIRA's Assessment Process
Consider a claimant who suffered a spinal injury in a car accident. SIRA would first review medical records confirming the injury's impact on mobility. If a doctor documents the need for assistance with dressing and mobility, SIRA will approve attendant care services. However, if the claimant's injuries are classified as 'threshold injuries' but the care need is not medically justified, SIRA may limit compensation.
When to Seek Legal Advice
SIRA's rules can be complex, especially when disputes arise over medical necessity or fault. Legal professionals can help claimants understand their rights, challenge decisions, or negotiate fair compensation. Independent advice is particularly valuable when a claimant's injuries overlap with workers' compensation or other benefits.
Next Steps for Claimants
If you or a loved one requires attendant care services following a motor accident, gather all relevant medical and accident documentation. SIRA's rules are strict, and claimants must prove their need for care through clear evidence. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.