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).
Chronic pain claims after a motor accident in NSW are governed by the Compulsory Third Party (CTP) scheme, which covers injuries meeting specific medical criteria. If you're experiencing ongoing pain following an accident in Illawarra or the South Coast, understanding how the scheme applies to your situation is critical. This article explains what chronic pain claims cover, how insurers assess them, and the evidence needed to support your case under NSW law.
What Chronic Pain Claims Cover Under NSW CTP
The NSW CTP scheme covers injuries that meet the definition of a 'threshold injury' under the Motor Accident Injuries Act 2017. For chronic pain to qualify, it must be linked to a spinal nerve-root injury producing neurological signs, or radiculopathy with specified clinical signs (as outlined in the Motor Accident Guidelines). Pain alone, without a diagnosed injury, typically does not qualify.
For example, if a car accident caused a herniated disc leading to persistent lower back pain and nerve-related symptoms, this may meet the threshold injury criteria. However, generalised pain without a specific injury is unlikely to be covered.
How Insurers Assess Chronic Pain Claims
Insurers like SIRA evaluate claims by reviewing medical evidence, including:
- Detailed treatment records from doctors or physiotherapists
- Imaging reports (e.g., MRI scans)
- Pain management plans
- Evidence of how the injury affects daily activities
In Illawarra and the South Coast, claims may take longer to process due to regional service delays. Insurers often request additional documentation to confirm the injury meets the threshold definition. If your claim is denied, you may need to escalate it for a formal review.
Evidence Needed for a Chronic Pain Claim
To support your claim, gather:
- Medical reports confirming a diagnosed injury linked to the accident
- A treatment plan showing ongoing care needs
- Proof of income loss or additional expenses
- Witness statements or accident reports
Keep records of all communication with insurers, as time limits apply. If your injury is classified as a 'threshold injury, ' benefits like weekly payments may be limited after 52 weeks under the scheme.
SIRA and Disputes Over Chronic Pain Claims
SIRA handles disputes by referring claims to an independent review. If you disagree with an insurer's decision, you can request a review within 28 days. In regional areas like Illawarra, delays in processing can prolong disputes, so it's important to act promptly. SIRA's role is to ensure claims are assessed fairly based on medical evidence, not the severity of pain alone.
When to Seek Legal Advice
If your claim is denied, or if you're unsure whether your injury meets the threshold criteria, consult a legal professional. Regional NSW has limited access to legal services, so early intervention can help navigate delays or disputes.
Next Steps
Chronic pain claims under NSW CTP require careful documentation and understanding of medical criteria. If you're in Illawarra or the South Coast and need guidance on your specific situation, complete the quick, no obligation enquiry form to request contact about your circumstances.