How NSW CTP Insurers Assess Chronic Pain Claims
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).
In New South Wales, insurers assess chronic pain claims under the Motor Accident Injuries Act 2017 and SIRA guidelines. Chronic pain following a motor accident is evaluated based on medical evidence, treatment records, and whether the injury meets the 'threshold injury' definition. Insurers consider factors like the nature of the pain, its impact on daily life, and medical reports confirming the injury's connection to the accident.
Key Factors in Chronic Pain Claims
Insurers evaluate claims by reviewing:
- Medical records: Imaging, specialist reports, and treatment plans showing a link between the accident and chronic pain.
- Impairment assessments: Whether the pain meets the spinal nerve-root or radiculopathy criteria in the Motor Accident Guidelines.
- Treatment history: Evidence of ongoing therapy, physiotherapy, or medication prescribed for the injury.
- Daily impact: Documentation of how the pain affects work, mobility, or personal care.
For example, if a person develops chronic back pain after a car accident, insurers will check if the pain stems from a spinal nerve-root injury (as defined in the guidelines) and whether it requires long-term management.
Time Limits and Dispute Options
Claims must be made within 52 weeks of the accident if only 'threshold injuries' are involved. If the injury exceeds threshold criteria, benefits may continue beyond this period. If an insurer denies a claim, you can:
- Request a review of their decision
- Lodge a complaint with the NSW Civil and Administrative Tribunal (NCAT)
- Seek independent medical opinions to challenge the assessment
Practical Steps for Claimants
To support your claim:
- Keep all medical records and treatment records
- Document how the pain affects your daily activities
- Seek clarification from your treating doctor about the injury's connection to the accident
- Contact the insurer within the 52-week timeframe unless you have evidence of a more severe injury
When to Seek Legal Advice
If your claim is denied or you're unsure about the insurer's decision, consult a legal professional. They can help you understand your options under the Motor Accident Injuries Act 2017 and ensure your claim meets the required standards.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.