Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
If you're involved in a NSW motor accident claim and disagree with a medical assessment, understanding your dispute resolution options is critical. Under the NSW Compulsory Third Party (CTP) scheme, medical assessments are central to determining your entitlements. This article explains how to challenge disputed assessments, navigate SIRA's processes in Bankstown, and protect your claim.
How SIRA Handles Medical Assessment Disputes
The State Insurance Regulatory Authority (SIRA) oversees CTP claims in NSW. When a medical assessment disputes your injury's severity or type, SIRA evaluates whether the assessment meets the Motor Accident Guidelines. For example, if a doctor labels your injury as a 'threshold injury' but you believe it's more severe, SIRA will assess whether the assessment aligns with the guidelines.
Key principles underpin SIRA's approach:
- Soft tissue injuries must involve spinal nerve-root damage with neurological signs (per the Motor Accident Guidelines).
- Threshold injuries are limited to specific clinical criteria, and claims for these injuries are restricted to 52 weeks of benefits under s 4.4 of the Motor Accident Injuries Act 2017.
- Independent medical reviews are available if you challenge an assessment.
Practical Steps for Challenging a Medical Assessment
If you disagree with a medical assessment, take these steps:
- Request a detailed explanation of the assessment. Ask why the injury was classified as a threshold injury or why certain treatment options were excluded.
- Gather supporting evidence. This includes:
- Your full medical records (including imaging and specialist reports)
- Notes from treating doctors about your symptoms and recovery
- Evidence of ongoing pain or functional limitations
- Any correspondence with SIRA or the insurer
- Seek an independent medical review. Under the CTP scheme, you can request a second opinion from a SIRA-approved medical expert. This process is outlined in SIRA's Making a Motor Accident Claim guidelines.
- Submit a written objection to SIRA. Clearly state your disagreement with the assessment and reference the evidence you've compiled. Ensure your objection is submitted within the 52-week statutory period unless you have a valid reason for delay.
Time Limits and When to Seek Advice
Time is critical in medical assessment disputes. Under the Motor Accident Injuries Act 2017, claims for threshold injuries are generally limited to 52 weeks of benefits. If your injury is classified as a threshold injury, you must ensure your claim is resolved within this timeframe.
If you're unsure whether your injury meets the threshold criteria or if you believe the assessment is incorrect, seek legal advice promptly. Delays can result in lost benefits or the inability to pursue further review.
Example: Disputing a Soft Tissue Injury Assessment
Consider this scenario: After a car accident in Bankstown, you're assessed as having a soft tissue injury. However, your doctor argues the injury involves spinal nerve-root damage with neurological signs, which may qualify as a threshold injury under the guidelines. SIRA will review whether the assessment meets the specific clinical criteria outlined in the Motor Accident Guidelines. If the assessment is disputed, you can request an independent review to challenge the classification.
Next Steps
Medical assessment disputes require careful navigation of SIRA's processes. If you're in Bankstown and facing a disagreement with a medical assessment, it's essential to act quickly. Contact a legal professional to ensure your claim is properly evaluated and that you understand your options under NSW CTP law.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.