How NSW CTP Insurers Assess Chronic Pain Claims
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 motor accidents in New South Wales are evaluated under the Motor Accident Injuries Act 2017 and SIRA guidelines. Insurers assess whether the pain meets the 'threshold injury' criteria, which requires a spinal nerve-root injury producing neurological signs or radiculopathy with specific clinical signs. Chronic pain alone, without meeting these criteria, may not qualify for ongoing benefits. Rural claimants may face additional challenges in accessing specialist medical assessments or timely insurer reviews.
Key Factors in Insurer Decisions
NSW CTP insurers consider several factors when evaluating chronic pain claims:
- Medical evidence: Detailed records from doctors, physiotherapists, and pain specialists are essential. These must link the pain to the accident and demonstrate its impact on daily life.
- SIRA guidelines: The Motor Accident Guidelines define what constitutes a threshold injury. Insurers use these to determine if a claimant qualifies for weekly income payments or treatment benefits.
- Duration of symptoms: Pain must be continuous and not intermittent. Insurers may request medical opinions confirming the pain is 'chronic' and not temporary.
- Location-specific challenges: Rural claimants may struggle to access SIRA-approved medical experts or face delays in obtaining necessary assessments due to limited local services.
Practical Steps for Claimants
To support a chronic pain claim, injured people should:
- Document all medical treatments, including consultations, scans, and therapy sessions.
- Keep records of how the pain affects work, sleep, or daily activities.
- Request a formal assessment from a SIRA-registered medical practitioner.
- Submit all evidence to the insurer within 52 weeks of the accident, as benefits may be limited after this period unless the claimant meets the threshold injury criteria.
Disputing Denied Claims
If an insurer denies a chronic pain claim, claimants can:
- Appeal the decision by submitting additional medical evidence or a revised assessment.
- Seek independent review through SIRA's dispute resolution process.
- Consult a legal professional if the claimant believes the insurer's decision is unfair or based on incorrect information.
Example Scenario
A rural resident involved in a low-speed collision experiences persistent back pain. After 12 months, the insurer denies a chronic pain claim, arguing the injury does not meet threshold criteria. The claimant submits a new MRI showing spinal nerve-root involvement and a specialist report confirming radiculopathy. This evidence may prompt the insurer to reconsider the claim under SIRA guidelines.
When to Seek Advice
Claimants in rural or remote areas should seek legal advice if:
- The insurer refuses to acknowledge the chronic nature of the pain.
- Medical assessments are delayed or not provided.
- The claimant is unsure whether their symptoms meet SIRA's threshold injury definition.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.