NSW CTP insurers evaluate child injury claims by prioritizing medical evidence, dependency calculations, and the child's long-term needs. Understanding how insurers assess these claims is critical for parents seeking compensation. This article explains the legal framework, practical steps, and common decision points insurers consider when determining child injury claims under the Motor Accident Injuries Act 2017.
Legal Framework for Child Injury Claims
NSW CTP insurers operate under the Motor Accident Injuries Act 2017, which outlines statutory benefits for injuries resulting from motor vehicle accidents. For children, the assessment focuses on two main categories: treatment and care benefits and weekly income benefits. These are calculated based on the child’s medical needs, not the fault of the driver. Under the Act, weekly benefits are available for 52 weeks if the injury meets the 'threshold injury' definition in the Motor Accident Guidelines. After this period, benefits are generally limited unless the child has a whole-person impairment of 10% or more.
Insurers also consider the child’s dependency on parents or guardians. For example, if a child requires ongoing care due to a soft tissue injury (like a whiplash), the insurer will assess the cost of treatment, lost income for caregivers, and the child’s future needs. This differs from common law damages claims, which are not available under the CTP scheme.
Practical Steps and Evidence That Matter
When a child is injured in a motor accident, parents must gather specific evidence to support a claim. Key documents include:
- Medical records showing the injury’s severity, treatment plan, and prognosis.
- Accident reports from police or witnesses to establish the incident.
- Income records of caregivers to calculate lost wages.
- Statements from healthcare professionals confirming the child’s dependency.
Insurers often request detailed medical assessments, including reports from specialists like paediatricians or physiotherapists. For example, if a child has a spinal nerve-root injury with neurological signs (even without radiculopathy), the injury may still qualify as a 'threshold injury' under the guidelines.
Common Reasons for Denied Claims and How to Challenge Decisions
Insurers may deny claims if:
- The injury does not meet the threshold injury definition.
- There is insufficient evidence of dependency or treatment costs.
- The claimant has not followed the required notice procedures (e.g., notifying the insurer within 52 weeks of the injury).
Parents can challenge decisions by:
- Requesting a review through the insurer’s internal process.
- Seeking independent medical opinions to dispute the insurer’s assessment.
- Consulting a legal professional if the claim is rejected or if the insurer refuses to negotiate.
A hypothetical example: A 7-year-old child sustains a soft tissue injury in a car accident. The insurer denies the claim, arguing the injury does not meet the threshold. However, medical records show the child requires ongoing physiotherapy and parental care, which impacts the family’s income. In this case, the insurer must reassess the claim based on the child’s long-term needs, not just the initial injury.
Time Limits and Next Steps
Claims must be submitted within 52 weeks of the injury for weekly benefits. If the injury is not a threshold injury, benefits stop after this period unless the child has a whole-person impairment. Parents should act quickly to gather evidence and notify the insurer. If the claim is denied, the next step is to request a review or seek legal advice.
When to Seek Legal Advice
Parents should consider legal assistance if:
- The insurer refuses to pay for necessary treatment.
- The claim is denied without a clear explanation.
- The child’s injury requires long-term care or has a high impairment rating.
Legal professionals can help navigate the CTP scheme, challenge insurer decisions, and ensure the child’s needs are fully addressed.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.