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 involved in a motor accident in NSW and disagree with a medical assessment of your injuries, understanding your rights and options is critical. Medical assessment disputes in NSW CTP claims often arise when injured road users challenge the conclusions of a medical report used to determine compensation. This article explains how to handle such disputes, including early steps to take, how insurers evaluate claims, and the role of SIRA guidelines.
What is a Medical Assessment Dispute in NSW CTP Claims?
A medical assessment dispute occurs when the injuries claimed by an injured road user (driver, passenger, pedestrian, cyclist, or motorcyclist) are evaluated by a medical practitioner, and the assessment is contested. Under the Motor Accident Injuries Act 2017, insurers must use a medical assessment to determine whether a claimant is eligible for benefits or damages. If the assessment concludes the injuries are not serious enough to qualify, the claimant may dispute the findings.
Early Steps for Injured Road Users
When a medical assessment dispute arises, injured road users should take the following steps:
- Seek independent medical advice, Obtain a second opinion from a medical practitioner who is not involved in the initial assessment. This can help challenge the conclusions of the original report.
- Document all evidence, Gather medical records, accident reports, witness statements, and photographs of the incident. These records are essential to support your case.
- Notify the insurer, Inform the CTP insurer of your disagreement with the medical assessment. SIRA guidelines require insurers to provide a written explanation of their assessment and the basis for their decision.
- Review the medical report, Carefully examine the original assessment for errors, inconsistencies, or omissions. Look for whether the report addresses all injuries and follows SIRA’s medical guidelines.
How NSW CTP Insurers Evaluate Medical Assessment Disputes
NSW CTP insurers evaluate disputes under the Motor Accident Injuries Act 2017 and SIRA guidelines. Key factors include:
- Threshold injury criteria, The insurer must determine whether the injuries meet the threshold for compensation. This includes assessing whether the injuries are serious enough to qualify for benefits under the Act.
- Spinal nerve-root qualification, Under SIRA guidelines, a spinal nerve-root injury producing neurological signs (other than radiculopathy) may still qualify as a soft-tissue injury. Radiculopathy requires specific clinical signs to be present.
- Weekly benefits and treatment, If the injuries are classified as threshold injuries, weekly benefits and treatment benefits may be limited after 52 weeks. This is a statutory restriction under s 4.4 of the Motor Accident Injuries Act 2017.
The Role of SIRA in Resolving Disputes
SIRA (State Insurance Regulatory Authority) oversees the CTP claims process in NSW. When a medical assessment dispute arises, SIRA provides guidelines for insurers to follow. If a claimant disagrees with the insurer’s decision, they can:
- Request a review, Submit a written request for a review of the medical assessment. SIRA requires insurers to provide a detailed explanation of their decision.
- Escalate to SIRA, If the insurer refuses to review the assessment, the claimant can escalate the matter to SIRA for further investigation.
- Seek independent medical review, SIRA may appoint an independent medical practitioner to reassess the injuries if there is a significant disagreement between the claimant and the insurer.
Practical Example: Disputing a Soft-Tissue Injury Assessment
Consider a scenario where a pedestrian is involved in a motor accident and is assessed as having a soft-tissue injury. The claimant disputes the assessment, arguing that they suffer from chronic pain and limited mobility. Under SIRA guidelines, the claimant should:
- Obtain a second medical opinion confirming the severity of their injuries.
- Submit the new report to the insurer, highlighting discrepancies in the original assessment.
- Request a review of the medical report under SIRA’s dispute resolution process.
Time Limits and When to Seek Advice
NSW CTP claims have strict time limits. For example, claims for injuries must generally be made within 52 weeks of the accident. If a medical assessment dispute arises after this period, the claimant may lose the right to seek compensation. It is essential to act quickly and seek legal advice if:
- The medical assessment is unclear or incomplete.
- The insurer refuses to review the assessment.
- The claimant believes the assessment underestimates the severity of their injuries.
Next Steps
Medical assessment disputes in NSW CTP claims can be complex. While the above steps provide a foundation, the outcome depends on the specific facts of your case. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.