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).
If your CTP claim is delayed and you need to prepare for medical assessments, understanding your rights and obligations under NSW law is critical. Insurers must respond to claims within set timeframes, but delays are common. This article explains how to prepare for medical assessments while navigating SIRA's requirements, focusing on the Illawarra and South Coast regions.
Legal Framework for Delayed CTP Decisions
Under the Motor Accident Injuries Act 2017, insurers must act promptly on claims. While there is no fixed deadline for all decisions, the 52-week statutory benefit rules apply to injuries meeting the 'threshold injury' definition. If your injuries are below this threshold, weekly benefits and treatment payments may stop after 52 weeks, regardless of ongoing medical treatment.
SIRA guidelines clarify that insurers must provide a 'decision notice' within 28 days of receiving a claim. If your insurer has not responded within this timeframe, you may have grounds to escalate the matter. However, delays in medical assessments can affect your ability to meet time-sensitive requirements, such as submitting evidence of ongoing treatment.
Practical Steps for Preparing Medical Assessments
When preparing for medical assessments, focus on gathering the following:
- Medical records: Ensure your treating practitioner has documented your injuries in line with the Motor Accident Guidelines. This includes clinical signs like radiculopathy (nerve-related pain radiating down a limb) or spinal nerve-root injuries.
- Accident details: Keep records of the incident, including police reports, witness statements, and photographs. These help establish the circumstances of the accident and support your claim.
- Income and treatment costs: Document your weekly income and any out-of-pocket expenses for medical care. This is essential for claiming weekly benefits.
In the Illawarra and South Coast, contact SIRA's regional offices directly for guidance. These areas have specific SIRA contact points, and delays in communication may require proactive follow-up.
Time Limits and Dispute Options
Insurers must respond to claims within 28 days of receiving all required information. If your claim is delayed beyond this period, you may need to:
- Request a written timeline from the insurer explaining their decision-making process.
- Escalate to SIRA if the insurer fails to respond within 28 days.
- Seek independent medical advice if you believe your assessment is incomplete or biased.
Disputes over medical assessments must be resolved through SIRA's internal review process. You cannot directly challenge an assessment in court unless you have legal representation.
When to Seek Legal Advice
If your insurer has delayed decisions for over 28 days, or if your medical assessments are being challenged, consider consulting a solicitor. Legal advice is particularly important if:
- Your injuries meet the 'threshold injury' definition but your benefits have stopped.
- You are facing disputes over the necessity of ongoing treatment.
- You need to challenge an insurer's refusal to cover medical costs.
Legal professionals can help you navigate SIRA's requirements and ensure your claim meets all statutory and guideline criteria.
Real-World Example
Consider a claimant in Wollongong who suffered a soft-tissue injury after a car accident. Their insurer delayed a decision for 30 days, during which time the claimant underwent a medical assessment. The insurer later refused to pay weekly benefits, arguing the injury did not meet the threshold. The claimant's solicitor reviewed the medical records and found the injury met the spinal nerve-root criteria under the Motor Accident Guidelines. This led to a successful review of the insurer's decision.
Next Steps
If your CTP claim is delayed and you need to prepare for medical assessments, act quickly. Document all evidence, follow up with your insurer, and consider legal advice if your rights are being challenged. Every claim depends on its own facts, and the Illawarra and South Coast have specific SIRA contact points to assist you.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.