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 insurer disputes the severity of your injury in a NSW CTP claim, you need to prepare a strong documentation package to support your case. This article explains what medical records, incident reports and expert evidence are essential to challenge an insurer's assessment of injury severity under NSW CTP laws. It also outlines how to prepare documentation for internal insurer reviews and references SIRA's requirements for disputed claims.
What Medical Records Are Essential for Disputing an Injury Assessment?
When an insurer disputes the severity of your injury, you must provide evidence that demonstrates the injury meets the threshold for compensation. Key documents include:
- Medical records showing diagnosis, treatment plans and recovery progress
- Clinical notes detailing neurological signs, imaging reports and specialist opinions
- Physiotherapy records documenting exercise regimes and progress
- Psychological assessments if mental health issues are claimed
- Expert medical opinions from specialists confirming injury severity
Under the Motor Accident Injuries Act 2017, injuries must produce neurological signs or meet specific impairment thresholds to qualify for compensation. For example, a spinal nerve-root injury producing neurological signs other than radiculopathy may still fall within the soft-tissue definition, as outlined in the Motor Accident Guidelines.
How to Prepare Documentation for an Insurer's Internal Review
Insurers in NSW typically conduct internal reviews before escalating disputes to the Personal Injury Commission (PIC) or SIRA. To prepare your documentation:
- Organise all medical records in chronological order, starting from the date of the accident
- Highlight clinical evidence that supports your injury claims, such as MRI scans or specialist reports
- Include incident reports from the accident, including police reports, witness statements and photographic evidence
- Provide income records to support claims for lost wages or reduced earning capacity
- Attach correspondence with the insurer showing your attempts to resolve the dispute
SIRA requires claimants to submit a detailed 'Claim Form' and supporting evidence when disputes arise. The insurer must respond within 28 days of receiving your documentation, as per SIRA's claim processing guidelines.
SIRA Guidelines for Disputed Injury Documentation
When an insurer disputes injury documentation, SIRA provides specific pathways for resolution. Key considerations include:
- Threshold injury assessments must be based on clinical evidence, not subjective claims
- Weekly benefits are available for injuries resulting in at least 20% impairment, as defined in the Motor Accident Guidelines
- Dispute resolution requires a 'Medical Dispute Review' by a SIRA medical assessor
- Escalation to PIC occurs if the insurer fails to respond within 28 days
If your insurer disputes the severity of your injury, you may need to request a medical review by a SIRA-approved assessor. This process is outlined in SIRA's 'Making a Motor Accident Claim' guidelines, which require claimants to submit a detailed 'Dispute Form' with supporting evidence.
Practical Example: Challenging an Insurer's Assessment
Consider a claimant who suffered a soft-tissue injury after a car accident in Bathurst. The insurer disputes the injury's severity, arguing it does not meet the threshold for compensation. To challenge this:
- Provide clinical evidence such as MRI scans showing soft-tissue damage
- Submit medical records from a specialist confirming the injury's impact
- Include witness statements and photographic evidence of the accident scene
- Attach income records showing lost wages due to the injury
- Request a medical dispute review through SIRA
This example illustrates how to use SIRA's guidelines to challenge an insurer's assessment. However, each case is unique, and the outcome depends on the specific evidence and legal interpretation.
Time Limits and When to Seek Advice
NSW CTP claims have strict time limits. You must notify the insurer of your claim within 28 days of the accident, as per the Motor Accident Injuries Act 2017. If the insurer disputes your claim, you have 28 days to respond to their initial assessment. If they fail to respond within this period, you may need to escalate the matter to SIRA.
If your insurer disputes your injury documentation, it is important to seek legal advice promptly. A solicitor can help you prepare a strong case and ensure all documentation meets SIRA's requirements. Remember, the outcome of a dispute depends on the specific facts of your case and the evidence you provide.
Next Steps for Claimants in Bathurst
If your insurer disputes your CTP claim, start by gathering all relevant documentation and preparing a detailed submission for their internal review. If the dispute continues, you may need to escalate the matter to SIRA or seek legal advice. Every claim depends on its own facts, and the available options may vary depending on the circumstances of your case. To request contact about your circumstances, complete the quick, no obligation enquiry form.