What the PIC Expects in Care and Family Support Disputes
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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 Compulsory Third Party (CTP) rules, the Prescribed Independent Contractor (PIC) evaluates claims for care and family support based on medical necessity, cost-effectiveness, and alignment with SIRA guidelines. If disputes arise over the validity or funding of such claims, the PIC assesses evidence to determine whether the care is essential and proportionate to the injury.
Key CTP Rules Behind Care Claims
NSW CTP claims under the Motor Accident Injuries Act 2017 allow for compensation covering care and family support if the injury meets the 'threshold injury' criteria. This includes paid and unpaid care needs arising from a motor accident. The PIC must consider:
- Medical evidence confirming the necessity of care (e.g., doctor’s reports, care plans);
- Cost records for family support services (e.g., invoices, receipts);
- Proportionality of care arrangements relative to the injury’s severity;
- SIRA guidelines on what constitutes reasonable and necessary support.
Evidence and Practical Steps for Claimants
To support a care and family support claim, claimants must provide:
- Medical documentation from a registered medical practitioner detailing the injury’s impact on daily living;
- Evidence of care arrangements (e.g., care provider contracts, family care logs);
- Financial records showing the cost of services;
- Witness statements or expert opinions where disputes arise.
If the PIC disputes the necessity of care, claimants should:
- Request a detailed written explanation of the PIC’s concerns;
- Submit additional evidence to clarify the care’s medical necessity;
- Seek independent medical review if the PIC’s assessment is challenged.
Time Limits and Dispute Resolution
Claimants must notify the PIC of disputes within 52 weeks of the accident (or 52 weeks from the last relevant treatment, if applicable). If the PIC refuses to fund care, claimants can:
- Apply for an internal review within the PIC’s organisation;
- Lodge a formal objection with the Personal Injury Commission (PIC) under the Motor Accident Injuries Act 2017;
- Pursue a review by the NSW Civil and Administrative Tribunal (NCAT) if the dispute escalates.
Disputes over care funding do not guarantee a changed decision. The PIC must demonstrate that the care arrangement does not meet the 'reasonable and necessary' standard under SIRA guidelines. Claimants should seek legal advice if the PIC’s decision is based on unclear or disputed medical evidence.
When to Seek Independent Advice
Disputes over care and family support claims often hinge on interpreting medical evidence and SIRA guidelines. If the PIC’s decision is based on incomplete information, conflicting medical opinions, or unclear cost assessments, claimants should consult a solicitor specialising in NSW CTP claims. Legal advice can help challenge the PIC’s interpretation of 'necessity' or 'proportionality' in care arrangements.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.