How NSW CTP Insurers Handle Medical Assessment Disputes
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 a medical assessment that affects your ability to return to daily activities after a motor accident in Newcastle or Hunter, understanding the NSW CTP process is critical. Under the Motor Accident Injuries Act 2017, insurers must evaluate claims based on medical evidence. Disputes often arise when assessments conflict with a claimant’s ability to perform routine tasks like cooking, shopping, or working. SIRA (State Insurance Regulatory Authority) oversees these disputes, ensuring assessments align with the Motor Accident Guidelines.
SIRA Guidelines for Medical Assessment Disputes
SIRA evaluates medical assessments by considering whether the findings are supported by clinical evidence. For example, if a doctor states you cannot return to work due to a soft-tissue injury, SIRA will review whether the injury meets the 'threshold injury' definition under the Motor Accident Guidelines. This includes assessing neurological signs and spinal nerve-root injuries. If the assessment is disputed, SIRA may request additional medical reports or consult with independent experts.
Practical Steps for Resolving Disputes
To challenge or support a medical assessment, gather evidence such as:
- Detailed medical records showing the injury’s impact on daily activities
- A second opinion from a specialist
- Documentation of specific tasks you can or cannot perform
- Witness statements about your functional limitations
If the insurer disputes the assessment, you may need to submit a formal objection through SIRA’s Personal Injury Commission (PIC) process. This involves a written review and, if unresolved, a hearing where both parties present evidence.
Time Limits and When to Seek Advice
You have 52 weeks from the accident date to claim weekly benefits for threshold injuries. After this period, benefits may be limited unless the injury is classified as a 'whole person impairment' (WPI). If a medical assessment disputes your capacity to return to daily activities, act quickly: SIRA has 28 days to respond to objections, and delays can jeopardize your claim.
Example: Disputing a Return-to-Work Assessment
Consider a claimant who sustained a soft-tissue injury and cannot return to their job as a nurse. The insurer’s assessment states they can return to light duties, but the claimant’s doctor says this is unsafe. SIRA will review whether the injury meets the threshold injury criteria and whether the assessment accurately reflects the claimant’s functional capacity. If the dispute persists, a PIC hearing may determine the correct assessment.
Next Steps
Medical assessment disputes require careful navigation of SIRA guidelines and evidence. If you’re unsure how to challenge or support an assessment, seek advice from a solicitor specialising in NSW CTP claims. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.