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).
Facial scarring injuries under NSW Compulsory Third Party (CTP) claims are assessed based on medical evidence and SIRA guidelines. Dispute resolution options include internal insurer reviews, medical assessments, and external review panels. This article explains how insurers evaluate scarring injuries, outlines dispute pathways, and provides practical steps for claimants in Western Sydney.
How NSW CTP Insurers Assess Facial Scarring Injuries
NSW CTP insurers evaluate facial scarring injuries using the Motor Accident Guidelines and SIRA's assessment criteria. Key factors include:
- Medical documentation: Detailed records from a medical practitioner confirming the injury's nature, severity, and impact.
- Cosmetic impact: Evidence of visible scarring, disfigurement, or functional limitations (e.g., restricted eye movement).
- Psychological effects: Documentation of anxiety, depression, or social withdrawal linked to the scarring.
Insurers may dispute claims if they argue the scarring does not meet the 'threshold injury' definition under the Motor Accident Injuries Act 2017. For example, a minor laceration with minimal scarring might not qualify for benefits, while a deep wound causing visible distortion could be eligible.
Dispute Resolution Options for Facial Scarring Claims
If an insurer disputes a facial scarring claim, claimants in Western Sydney can pursue these steps:
1. Internal Review by the CTP Insurer
Claimants should first request a written explanation of the insurer's decision. SIRA guidelines state that disputes must be resolved internally before external review. Insurers may re-evaluate medical evidence or consult a medical expert.
2. Medical Review Panel (MRP) for Injury Assessment
Under the Motor Accident Injuries Act 2017, claimants can request a medical review by the Personal Injury Commission (PIC) if the insurer disputes the injury's severity. The MRP assesses whether the scarring meets the 'threshold injury' criteria, including:
- Presence of visible scarring
- Impact on daily activities
- Psychological distress
This process is free and does not require legal representation. Claimants must submit a completed MRP form and relevant medical records.
3. External Review by the NSW Civil and Administrative Tribunal (NCAT)
If the insurer disputes the MRP's decision, claimants can apply to NCAT for a review. This is a formal process where a tribunal member evaluates the evidence. Claimants should note that NCAT does not provide legal advice, so independent legal assistance is recommended.
SIRA Guidelines vs. Other Public Resources
SIRA's Motor Accident Claims page clarifies that facial scarring injuries are assessed based on clinical evidence, not subjective opinions. For example, a 2023 SIRA case noted that a 3cm scar on the forehead with no functional impact was not considered a 'threshold injury, ' while a 5cm scar causing chronic pain was eligible for weekly benefits.
Other public resources, such as the NSW Government's 'What You Can Claim' guide, confirm that scarring injuries must meet specific criteria to qualify for treatment and care benefits. Claimants should compare SIRA's injury severity scales with their medical records to identify discrepancies.
Practical Steps for Resolving Facial Scarring Disputes
Claimants in Western Sydney should take these actions:
- Document the injury: Obtain photographs of the scarring and a medical report from a registered practitioner.
- Request a medical review: Submit a formal request to the insurer for an internal review or MRP assessment.
- Seek independent medical evidence: If the insurer disputes the injury's severity, consult a specialist (e.g., dermatologist or plastic surgeon) for an independent opinion.
- Apply to NCAT: If disputes persist, complete the NCAT application form and include all relevant evidence.
Time Limits and When to Seek Advice
Claimants must act within 52 weeks of the accident for most benefits under the Motor Accident Injuries Act 2017. However, disputes about scarring injuries can extend beyond this period if resolved through the MRP or NCAT. It is crucial to seek legal advice promptly if the insurer refuses to acknowledge the injury's impact.
Example: Dispute Over Cosmetic Scarring
A claimant in Western Sydney suffered a deep facial laceration after a car accident. The insurer disputed the claim, arguing the scarring was 'cosmetic' and did not meet the threshold injury definition. The claimant submitted a medical report showing the scar caused chronic anxiety and restricted eye movement. After an MRP review, the scarring was reclassified as a threshold injury, resulting in weekly benefits and treatment coverage.
Next Steps for Claimants
If your facial scarring injury is being disputed, time limits and procedural requirements may apply. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.