Understanding Insurer Decisions in Child Injury Claims
When a child is injured in a motor accident in the Newcastle and Hunter region, insurers assess claims under the Motor Accident Injuries Act 2017 and related regulations. Decisions about compensation are not arbitrary but follow a structured legal framework. Insurers consider whether the child has sustained a threshold injury, whether treatment and care benefits are appropriate, and whether a claim for damages may proceed. These assessments are guided by the Motor Accident Injuries Regulation 2017 and the Motor Accident Guidelines issued by the State Insurance Regulatory Authority (SIRA). The outcome depends on medical evidence, the nature and duration of injuries, and compliance with procedural requirements.
Key Factors in Insurer Assessments
Insurers in the Newcastle and Hunter region assess child injury claims based on several legal and evidentiary factors. First, they determine whether the child has sustained a threshold injury as defined under the Motor Accident Injuries Act 2017. This includes injuries such as a spinal nerve-root injury with neurological signs, or a permanent impairment of at least 10% to the whole person. For a child, the assessment must consider developmental impact and long-term functional outcomes.
Second, insurers review the medical evidence to assess the severity and duration of injuries. This includes reports from medical practitioners, diagnostic imaging, and records of treatment. A child’s recovery may be slower than an adult’s, and insurers must account for this in their evaluation of treatment and care benefits.
Third, insurers assess whether the injury resulted from a motor vehicle accident involving a vehicle registered in NSW or operating on NSW roads. The location of the accident, whether in a car park, driveway, or public road, does not automatically exclude coverage. The legal character of the vehicle’s use and the nature of the accident are assessed on a case-by-case basis.
Common Reasons for Delay or Rejection
Insurers may delay or reject a child injury claim for several reasons. A common reason is insufficient medical evidence to establish a threshold injury. For example, if a child presents with soft tissue injury and no objective neurological signs, the insurer may determine that the injury does not meet the threshold for damages. This is particularly relevant for injuries involving the neck or back, where radiculopathy must be demonstrated through clinical signs such as sensory loss or muscle weakness.
Another reason for rejection is the absence of a formal claim lodged within the required timeframes. While there is no fixed deadline for reporting an accident, claims for treatment and care benefits must be made within 12 months of the accident. Failure to notify the insurer within this period may result in a claim being denied.
Insurers may also dispute the causal link between the accident and the injury. If a child had pre-existing conditions or injuries, the insurer may argue that the current symptoms are not attributable to the motor accident. In such cases, a medical assessment by an independent practitioner may be required.
Evidence That Matters
The strength of a claim often depends on the quality and type of evidence collected. For a child injury claim, the following records are essential:
- Medical reports from treating practitioners, including assessments of pain, function, and progress
- Diagnostic imaging such as MRI or X-ray results
- Treatment records showing the frequency and type of therapy received
- School or educational reports if the injury affects learning or participation
- Photographs of the accident scene, vehicle damage, or visible injuries
- Witness statements, particularly from parents or caregivers who observed the child’s symptoms post-accident
Insurers in the Newcastle and Hunter region rely on this evidence to determine whether benefits should be granted and whether a claim for damages may proceed.
Dispute and Review Options
If an insurer refuses a claim or offers a settlement that does not reflect the child’s needs, the claimant may seek a review. The first step is to request a formal review from the insurer, which must be completed within 28 days of the decision. If the insurer upholds the original decision, the claimant may apply to the Civil and Administrative Tribunal (NCAT) for a determination under the Motor Accident Injuries Act 2017.
A claimant may also request a review by SIRA if there is a dispute about the interpretation of the Motor Accident Guidelines. SIRA does not make binding decisions but provides guidance that may influence the outcome of a dispute.
Hypothetical Example
A 10-year-old child was a passenger in a car that collided with a tree in a suburban area of Maitland. The child sustained a neck injury and was diagnosed with a spinal nerve-root injury showing sensory changes in the right arm. The treating neurologist confirmed the injury was caused by the accident and that it had not resolved after 40 weeks of treatment. The insurer initially declined to pay damages, arguing that the injury did not meet the threshold because no radiculopathy was confirmed. However, the medical evidence showed objective neurological signs, and a second opinion supported the diagnosis. The claimant applied to NCAT, which upheld the claim based on the medical evidence and SIRA’s interpretation of the guidelines.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.