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 NSW Compulsory Third Party (CTP) claim is under review by an insurer, understanding the internal dispute process and medical assessment requirements is critical. Insurers may request medical assessments to challenge your claim, especially if they dispute the severity of your injury. This article explains how to prepare for these assessments under NSW law, including SIRA guidelines and practical steps to challenge insurer decisions.
How Insurer Internal Reviews Work in NSW CTP Claims
NSW insurers must follow strict rules when disputing CTP claims. Under the Motor Accident Injuries Act 2017, insurers can request medical assessments to evaluate your injury's severity. These assessments are typically conducted by approved medical practitioners, and the insurer must provide written notice of their intent to challenge your claim.
Insurers cannot unilaterally change your claim outcome without first seeking reconsideration. If your claim is denied or reduced, you have the right to request an internal review before escalating to the Personal Injury Commission (PIC) or SIRA. This process allows you to challenge the insurer's decision based on medical evidence and SIRA guidelines.
Practical Steps to Prepare for Medical Assessments
When preparing for a medical assessment, focus on three key areas: your injury documentation, the insurer's request details, and SIRA's assessment protocols.
- Medical Evidence: Gather all relevant medical records, including diagnostic reports, treatment notes, and specialist opinions. Ensure your records clearly show how your injury meets the threshold injury definition under the Motor Accident Guidelines. For example, if your injury involves spinal nerve-root damage with neurological signs, this may qualify as a threshold injury.
- Insurer's Request: Review the insurer's written notice of their assessment request. Note the specific injury they are disputing and any conditions they apply. If the insurer claims your injury does not meet the threshold, you must demonstrate how your medical evidence contradicts this.
- SIRA Guidelines: SIRA's Motor Accident Guidelines outline how injuries are assessed for CTP claims. Familiarize yourself with these guidelines to challenge the insurer's interpretation of your injury. For instance, if your injury involves radiculopathy, ensure your medical records include the specified clinical signs outlined in the guidelines.
Time Limits and When to Seek Advice
Insurers have 52 weeks from the date of your accident to challenge your claim under the 'only injuries' rule. If your injury is a threshold injury and your claim is denied after 52 weeks, you may lose weekly benefits and treatment payments. However, this rule does not apply if your injury involves whole person impairment (WPI) or long-term care needs.
If your insurer refuses to reconsider their decision or escalates the dispute to SIRA, you should seek legal advice immediately. SIRA has strict timelines for resolving disputes, and delays can jeopardize your entitlements.
Hypothetical Example: Challenging a Disputed Injury
Consider a claimant in Ashfield who suffered a soft-tissue injury after a car accident. The insurer disputes the injury's severity, claiming it does not meet the threshold. The claimant must demonstrate that their medical records show neurological signs beyond radiculopathy, such as sensory loss or motor weakness. By referencing SIRA's guidelines, the claimant can challenge the insurer's assessment and request a reassessment.
Next Steps
Every CTP claim is unique, and the outcome depends on your injury, the insurer's actions, and your ability to challenge their decisions. If your insurer is disputing your claim or requesting a medical assessment, contact a legal professional to ensure your rights are protected. Complete the quick, no obligation enquiry form to request contact about your circumstances.