Disputes over medical assessments in NSW Compulsory Third Party (CTP) claims often centre on whether an injured person can return to daily activities. These disputes require careful evaluation of medical evidence under the Motor Accident Injuries Act 2017 (MAIA) and SIRA’s guidelines. This article explains how claimants and legal representatives handle such disputes, focusing on the practical steps, evidence needed, and time limits under NSW law.
How SIRA Assesses Medical Assessment Disputes
SIRA evaluates disputes by examining whether the medical evidence supports the claimant’s ability to perform daily activities. Under the MAIA, SIRA considers whether the injury meets the threshold for compensation, including the capacity to engage in routine tasks like cooking, shopping, or work. A key factor is whether the medical assessment aligns with the claimant’s reported symptoms and functional limitations.
Disputes often arise when a medical report contradicts the claimant’s testimony about their daily activities. SIRA may request additional assessments or consult with the Personal Injury Commission (PIC) to resolve conflicts. For example, if a doctor states a claimant cannot work but the assessment shows they can perform light household tasks, SIRA will weigh both perspectives.
Common Reasons for Disputes Over Daily Activity Capacity
- Inconsistent Medical Evidence: A doctor’s report may not reflect the claimant’s subjective experience of pain or mobility restrictions. For instance, a claimant might struggle with stairs but the assessment notes no musculoskeletal issues.
- Threshold Injury Determination: If the injury is classified as a 'threshold injury' (e.g., soft tissue damage), weekly benefits may stop after 52 weeks under s 4.4 of the MAIA. Claimants must prove their injury exceeds this threshold.
- Workplace or Household Activity Restrictions: Disputes may occur when a claimant’s ability to work or manage household duties is questioned, even if they can perform basic tasks.
How to Challenge a Medical Assessment
Claimants can challenge a medical assessment by:
- Providing additional evidence: Submitting updated medical records, therapy notes, or a second opinion from a specialist.
- Documenting daily activities: Keeping a journal of tasks completed, such as cooking, shopping, or walking distances.
- Engaging legal representation: A solicitor can help request a review by SIRA or escalate the matter to the PIC.
SIRA may also involve the PIC to mediate disputes. The PIC’s role includes assessing whether the medical evidence supports the claimant’s capacity to return to daily activities. However, a challenge does not guarantee a changed decision, the onus is on the claimant to demonstrate inconsistencies or errors in the original assessment.
Time Limits and Practical Steps
Disputes must be resolved within the 52-week statutory period for weekly benefits if the injury is limited to threshold injuries. Claimants should act quickly to:
- Notify SIRA of disputes within the claim timeline.
- Submit evidence promptly to support their case.
- Seek legal advice if the dispute escalates to a review by the PIC.
If a claimant believes their medical assessment is incorrect, they should contact SIRA directly or consult a solicitor to explore options. Remember, the outcome depends on the specific facts of the case and the quality of the evidence provided.
Next Steps
CTP claims involving medical assessment disputes require careful navigation of SIRA’s processes and the MAIA. While disputes can delay resolution, proper evidence and timely action can help claimants secure the support they need. For personalised guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.