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 you're disputing an insurer's decision about your medical condition after a motor accident in NSW, understanding the internal review process is critical. Insurers must follow specific rules under the Motor Accident Injuries Act 2017 before escalating claims to the Personal Injury Commission (PIC) or SIRA. This article explains how to prepare for medical assessments during disputes, what evidence matters, and when to seek legal advice.
The NSW CTP Rules Behind Insurer Internal Reviews
Under the NSW CTP scheme, insurers must assess claims based on medical evidence and SIRA guidelines. If an insurer disputes a claimant’s medical condition or treatment, they must first conduct an internal review. This process involves:
- Re-evaluating the medical evidence provided by your treating practitioner
- Consulting their own medical experts if necessary
- Deciding whether to uphold, amend, or reject the claim
Insurers cannot directly challenge a claimant’s medical records without first following this internal review. If they disagree with the outcome, they must escalate the matter to the PIC or SIRA for further review.
Practical Steps to Prepare for Medical Assessments
When disputing an insurer’s decision, you must prepare detailed medical evidence to support your claim. Key steps include:
- Gather all medical records: Ensure your treating doctor provides a clear report detailing your injuries, treatment, and recovery progress. This includes imaging, test results, and notes from consultations.
- Document the accident: Keep records of the incident, such as police reports, witness statements, and photographs of the scene. This helps establish the context for your injuries.
- Understand SIRA guidelines: SIRA’s Motor Accident Guidelines outline what constitutes a threshold injury or significant impairment. Familiarize yourself with these to challenge any misinterpretations of your condition.
- Prepare for expert assessments: If the insurer requests an independent medical opinion, ensure your treating practitioner is prepared to explain their diagnosis and treatment rationale.
Time Limits and Dispute Options
Insurers must act within specific timeframes when disputing claims. Under the Motor Accident Injuries Act 2017, they must notify you of their decision to review your claim within 28 days of receiving your medical records. If they fail to act within this period, you may have grounds to challenge their delay.
If the insurer’s internal review concludes your injuries are not as severe as claimed, you can request a formal review by the PIC or SIRA. These bodies have the authority to reassess medical opinions and determine whether your claim should proceed. However, it’s important to note that a challenge does not guarantee a change in the insurer’s decision.
When to Seek Legal Advice
Disputing an insurer’s decision can be complex, especially when medical assessments are involved. A solicitor can help you:
- Challenge the insurer’s interpretation of your medical records
- Ensure all required documentation is submitted correctly
- Navigate the SIRA review process if your claim is escalated
Legal advice is particularly valuable if the insurer refuses to provide a written explanation for their decision or if they delay the review process.
Example: Disputing a Threshold Injury Assessment
Consider a claimant who suffered a soft-tissue injury after a collision. The insurer disputes the injury’s severity, arguing it does not meet the threshold injury definition under SIRA guidelines. The claimant must provide evidence such as:
- A detailed medical report from their doctor explaining the injury’s impact
- Evidence of ongoing symptoms, such as pain or limited mobility
- Documentation of treatment received, including physiotherapy sessions
If the insurer’s internal review still disputes the injury, the claimant can request a formal review by SIRA. This process allows for a second opinion from independent medical experts.
Next Steps
CTP claims depend on the timing of the accident, the nature of the injuries, and the evidence you provide. If you’re in Albury and facing an insurer dispute, it’s essential to act promptly to preserve your rights. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.