Transitional claims under the MAI Act, what insurers expect in disputes
If you're involved in a motor accident that occurred before 1 December 2017, your claim may fall under the transitional provisions of the Motor Accident Injuries Act 2017 (MAI Act). Insurers, including the Personal Injury Commission (PIC), have specific expectations for these claims, particularly when disputes arise. This article explains what insurers typically require to assess transitional claims, how disputes commonly occur, and practical steps to meet insurer expectations.
Key expectations of insurers for transitional claims
Insurers assess transitional claims based on the legal framework that applied at the time of the accident. For claims involving both pre- and post-2017 incidents, the PIC evaluates whether injuries fall within the 'threshold injury' definition under the MAI Act. Key expectations include:
- Clear evidence of injury timing: Insurers require documentation showing when injuries occurred, as transitional claims involve overlapping legal rules. For example, if an injury was sustained before 1 December 2017 but treatment continued after, the PIC will assess whether the injury meets the MAI Act’s threshold criteria.
- Compliance with SIRA guidelines: The State Insurance Regulatory Authority (SIRA) provides detailed guidelines on what constitutes a threshold injury. Insurers expect claimants to provide medical records confirming neurological signs, imaging results, and clinical assessments that align with these guidelines.
- No fault disputes: Under the MAI Act, fault does not affect compensation entitlements for threshold injuries. However, insurers may challenge claims if they believe the injury does not meet the threshold, even if the accident occurred before the MAI Act’s implementation.
Common disputes in transitional claims
Disputes often arise when there is ambiguity about whether an injury qualifies as a 'threshold injury' under the MAI Act. For example, a claimant who suffered a soft tissue injury (like a whiplash) before 2017 may face challenges proving that the injury meets the updated definition under the MAI Act. Insurers may also dispute claims where the injury’s onset date is unclear or where medical evidence does not clearly support the injury’s existence.
A common scenario involves a claimant who sustained an injury before 1 December 2017 but continued to experience symptoms after that date. Insurers may argue that the injury does not meet the MAI Act’s threshold criteria, even if the pre-2017 legal framework would have covered it. In such cases, the PIC may request additional medical evidence to determine whether the injury falls within the transitional provisions.
Practical steps to meet insurer expectations
To strengthen your transitional claim, take the following steps:
- Document injury timing: Provide a clear timeline of when the injury occurred, including medical records that specify the date of diagnosis. If the injury was sustained before 1 December 2017 but treatment continued after, ensure this is explicitly stated in your claim.
- Follow SIRA guidelines: Review the SIRA guidelines on what constitutes a threshold injury. If your injury meets the criteria, ensure your medical evidence aligns with the specified neurological signs and clinical indicators.
- Address fault disputes proactively: While fault does not affect compensation under the MAI Act, insurers may challenge claims by questioning the injury’s validity. If you believe the PIC is disputing your claim unfairly, seek legal advice to challenge their assessment.
- Seek independent medical review: If the PIC requests a medical review, ensure your treating practitioner provides detailed documentation supporting your injury’s existence and its connection to the accident.
Time limits and dispute resolution
Under the MAI Act, claimants have three years from the date of the accident to make a claim. However, transitional claims may involve additional time limits if the injury’s onset date is disputed. For example, if the PIC argues that the injury did not occur within the transitional period, you may need to provide evidence to counter this.
If a dispute arises, you can request an internal review with the PIC. The PIC’s internal review process allows claimants to challenge decisions by submitting new evidence or requesting a medical assessment. If the dispute escalates, you may need to seek legal representation to challenge the PIC’s findings in the NSW Civil and Administrative Tribunal (NCAT).
When to seek legal advice
Transitional claims can be complex, especially when disputes involve overlapping legal frameworks. If you are unsure whether your injury meets the threshold criteria under the MAI Act, or if the PIC is challenging your claim, it is advisable to seek legal advice. A solicitor can help you navigate the claims process, challenge unfair decisions, and ensure your rights under the MAI Act are protected.
Next steps
Understanding what insurers expect in transitional claims is essential for claimants navigating the MAI Act’s unique provisions. By providing clear evidence of injury timing, following SIRA guidelines, and addressing disputes promptly, you can strengthen your claim. If you are unsure about your options or need assistance with a specific claim, complete the quick, no obligation enquiry form to request contact about your circumstances.