Understanding Transitional Claims Under the MAI Act in NSW
Motor accident claims in New South Wales that arose before 1 December 2017 are governed by the Motor Accidents Compensation Act 1999 (MACA). Claims that began after that date fall under the Motor Accident Injuries Act 2017 (MAIA). A transitional claim occurs when an injury from an accident before 1 December 2017 results in ongoing symptoms or a condition that persists into the MAIA regime. These claims may involve disputes over entitlements, benefits, or the assessment of impairment, particularly in Greater Sydney where claim volumes are high and insurer practices vary.
The Personal Injury Claimant (PIC) in a transitional claim is expected to actively engage with the insurer and, if necessary, the Personal Injury Commission (PIC) to resolve disputes. The PIC’s role is not passive; they must provide evidence, respond to medical assessments, and participate in review processes. The expectation is that the PIC will act in good faith and with reasonable diligence to progress the claim under the legal framework that applies at the time of the injury and the time of dispute.
What the PIC Is Expected to Do During a Dispute
When a dispute arises over a transitional claim under the MAI Act, the PIC is expected to meet several practical obligations. These are not legal obligations in the sense of binding duties, but they are standard expectations that influence the outcome of a dispute.
The PIC must provide a complete and accurate record of all medical treatment received since the accident. This includes records from general practitioners, specialists, physiotherapists, and any mental health professionals. The insurer and the Personal Injury Commission rely on this evidence to assess the nature and extent of the injury, and to determine whether the injury qualifies as a threshold injury under the MAIA.
The PIC must also respond promptly to requests for information from the insurer or the Commission. Delays in providing medical reports, treatment summaries, or correspondence can affect the progress of the claim. The PIC is expected to keep copies of all correspondence, including emails and letters, and to note the date and nature of each communication.
If the insurer disputes the claim or refuses a benefit, the PIC may request an internal review. This must be done within 28 days of receiving the insurer’s decision. The PIC must clearly state the grounds for disagreement and attach any supporting evidence. Failure to request an internal review within this timeframe may prevent the claim from progressing to the Commission.
How SIRA’s Guidance Shapes Dispute Outcomes
The State Insurance Regulatory Authority (SIRA) provides guidance on how transitional claims should be managed under the MAIA. While SIRA does not make binding decisions, its guidance is a key reference point for insurers, claimants, and the Personal Injury Commission.
SIRA’s position is that transitional claims must be assessed under the law that was in force at the time of the accident, unless a change in law or medical evidence justifies a different approach. For example, if a claimant suffered a soft tissue injury in 2016 but a diagnosis of a spinal nerve-root injury was confirmed in 2024, the PIC may seek to have the injury assessed under the MAIA’s more detailed threshold injury provisions.
SIRA also expects that medical evidence in transitional claims must be current and relevant. A medical report from 2018 may not be sufficient to establish ongoing impairment in 2026. The PIC must ensure that any medical assessment used in a dispute is conducted within the last 12 months, unless there is a compelling reason for an older report.
In Greater Sydney, where claim volumes are high, the PIC is expected to be proactive in managing disputes. SIRA has noted that delays in dispute resolution often stem from incomplete evidence or failure to respond to requests. The PIC who provides timely, complete documentation is more likely to have their dispute resolved in their favour.
Practical Steps to Take When a Dispute Arises
If a dispute arises over a transitional claim under the MAIA, the PIC should take the following steps:
- Immediately contact the insurer to request a written explanation of the decision that caused the dispute.
- Gather and organise all medical records, treatment notes, and correspondence related to the injury.
- Request a copy of any medical report used in the insurer’s decision, and seek a second opinion if necessary.
- Submit a formal internal review request within 28 days of receiving the insurer’s decision.
- If the internal review is denied, apply to the Personal Injury Commission for a review within 28 days of receiving the review outcome.
The PIC should not assume that a dispute will be resolved automatically. The process is not automatic, and the PIC must take active steps to progress the claim.
Medical Disputes and the Personal Injury Commission Pathway
If the dispute involves a medical assessment, such as the level of whole person impairment (WPI), the PIC may need to use the Personal Injury Commission’s medical dispute pathway. This allows the PIC to challenge a medical report that they believe is inaccurate or incomplete.
To use this pathway, the PIC must submit a formal challenge to the Commission within 28 days of receiving the medical report. The Commission will then appoint an independent medical assessor to review the evidence. The PIC must provide all relevant medical records and may attend a medical assessment.
The Commission will assess whether the original medical report was reasonable and supported by evidence. The PIC must be prepared to justify their position with clear medical documentation.
Time Limits and the Importance of Acting Promptly
Time limits are critical in transitional claims. The PIC must act within 28 days to request an internal review, and within 28 days after that to apply to the Commission. Missing these deadlines may result in the claim being closed or barred.
There is no automatic extension for transitional claims. The PIC must be aware that the MAIA’s 52-week limit on treatment and care benefits applies only to claims where the only injuries are threshold injuries. This does not apply to transitional claims where the injury was sustained before 1 December 2017, and the claimant is still receiving treatment.
The PIC should not delay seeking advice. The law is complex, and the expectations of the insurer and the Commission can vary depending on the nature of the injury, the location of the accident, and the evidence available.
A Realistic Example: A Transitional Claim in Greater Sydney
A 42-year-old woman was involved in a motor vehicle accident in Sydney’s Eastern Suburbs in 2015. She sustained a whiplash injury and received treatment for three years. In 2024, she was assessed as having a 12% whole person impairment due to a spinal nerve-root injury, which was not diagnosed until 2023. Her insurer, under the MACA regime, initially refused to recognise the injury as a threshold injury.
The PIC responded by gathering all medical records, including MRI results and specialist reports from 2023 and 2024. She submitted a formal internal review request within 28 days. The insurer upheld its decision. The PIC then applied to the Personal Injury Commission, which referred the matter to an independent medical assessor. The assessment confirmed the injury met the threshold injury criteria under the MAIA, and the PIC was awarded compensation for ongoing treatment and weekly payments.
This example illustrates that transitional claims in Greater Sydney are not automatically resolved in favour of the insurer. The PIC’s active engagement with the process, supported by strong medical evidence, can lead to a favourable outcome.
Next Steps for the Personal Injury Claimant
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