How CTP Insurers Assess Liability for Home Modifications in Serious Injuries
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).
In New South Wales, insurers assess claims for home modifications following serious motor accidents by evaluating the injury's impact, medical necessity, and the modification's direct link to the accident. This applies to all regions, including the Illawarra and South Coast, where claimants may require accessibility upgrades due to injuries like spinal cord damage or limb loss. The Motor Accident Injuries Act 2017 (MAIA) and SIRA guidelines govern these assessments, ensuring claims align with statutory thresholds and medical evidence.
Key Factors in Liability Assessments
NSW CTP insurers consider three main factors when evaluating home modification claims:
- Medical necessity: Doctors must confirm the modification is essential for the injured person's recovery, such as a wheelchair ramp for a spinal injury.
- Direct injury link: The modification must address a consequence of the accident, not a pre-existing condition. For example, a handrail installation following a fractured wrist.
- Cost justification: Modifications must be reasonably priced and reflect standard medical practices. SIRA's guidelines state claims must be 'necessary, reasonable, and not excessive' (SIRA - What you can claim).
Insurers in regional areas like the Illawarra may have additional scrutiny due to limited access to specialist medical reports. Claimants should ensure all documentation clearly connects the modification to the accident.
Practical Steps for Supporting a Claim
To strengthen a home modification claim, injured persons should:
- Obtain a detailed medical report from a specialist confirming the injury's severity and the modification's necessity.
- Provide cost records showing the modification's price and that it meets standard accessibility standards.
- Document how the modification improves daily living, such as through a mobility assessment.
- Submit any expert opinions from occupational therapists or physiotherapists.
For example, a claimant with a traumatic brain injury requiring a stair lift would need a neurologist's report linking the injury to the modification's necessity.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident for certain benefits under the MAIA. However, claims for home modifications may extend beyond this period if the injury's impact is ongoing. Disputes often arise when insurers question the modification's medical necessity or cost. Claimants should:
- Seek legal advice within 52 weeks if benefits are denied.
- Request a review of the insurer's decision using the formal dispute process outlined by SIRA.
- Consider mediation if the claim involves complex medical evidence.
When to Seek Independent Advice
CTP insurers in regional NSW may have limited experience with home modification claims, leading to inconsistent assessments. Independent legal advice is recommended if:
- The insurer denies the claim without clear reasoning.
- The claimant requires a second medical opinion.
- The modification involves specialist equipment or construction.
Independent solicitors can help navigate the process, ensuring all evidence meets SIRA's standards and the claim aligns with the MAIA's requirements.
Next Steps
CTP entitlements depend on the accident date, injury type, and claim history. To request contact about your circumstances, complete the quick, no obligation enquiry form.