Medical Assessment Disputes in NSW CTP Claims
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).
Medical assessment disputes are common in New South Wales Compulsory Third Party (CTP) claims when there is disagreement between the claimant and the insurer about the nature, severity, or ongoing impact of an injury. These disputes often arise when the injury does not meet the insurer’s criteria for long-term benefits or when the claimant believes the assessment is inaccurate. In regional NSW, where access to specialist medical services may be limited, these disputes can be particularly complex. This article explains how such disputes are resolved under NSW CTP rules, the role of SIRA guidelines, and practical steps to address them.
Key NSW CTP Rules Behind Medical Disputes
Under the Motor Accident Injuries Act 2017 (MAIA), injuries are classified as either 'threshold injuries' or 'whole person impairment' injuries. Threshold injuries are minor and typically do not qualify for ongoing weekly payments or treatment benefits after 52 weeks. Whole person impairment injuries, however, may entitle claimants to long-term support. Disputes often occur when an injury is initially assessed as a threshold injury but later appears to meet the criteria for a whole person impairment. SIRA’s Motor Accident Guidelines provide the clinical standards for these assessments, including specific neurological and functional criteria. In regional NSW, claimants may face additional challenges in accessing independent medical opinions due to limited specialist availability.
Practical Steps to Resolve Medical Disputes
- Seek Independent Medical Evidence: If the insurer’s assessment is disputed, claimants should request an independent medical report from a registered medical practitioner. This report must clearly outline the injury’s severity and its impact on daily life. In regional areas, claimants may need to travel to a major city for specialist assessments.
- Lodge a Review with the Personal Injury Commission (PIC): If the claimant disagrees with the insurer’s decision, they can request a review by the PIC. The PIC will assess whether the injury meets the criteria for whole person impairment. This process is free and does not require legal representation.
- a Document All Communications: Keep copies of all correspondence with the insurer, including medical reports, treatment records, and any requests for further assessments. This evidence is crucial if the dispute escalates to a formal review.
- Understand Time Limits: While there is no strict deadline for disputing an assessment, delays can affect the outcome. For example, if a claimant’s injury worsens over time, they may need to demonstrate that the initial assessment was based on incomplete information.
Example: A Regional NSW Dispute
Consider a claimant in regional NSW who was involved in a car accident and initially assessed as having a soft-tissue injury (a threshold injury). The insurer denied ongoing benefits, but the claimant later sought an independent assessment. The report revealed the injury involved a spinal nerve-root injury with neurological signs, meeting the criteria for a whole person impairment under the Motor Accident Guidelines. The PIC reviewed the evidence and adjusted the claimant’s benefits accordingly. This example highlights how access to specialist medical opinions and the PIC’s review process can resolve disputes in regional areas.
When to Seek Legal Advice
While the PIC process is designed to resolve most disputes, claimants may need legal assistance if the insurer refuses to cooperate or if the dispute involves complex legal issues such as contributory fault or overlapping workers’ compensation claims. Legal advice is also recommended if the claimant is unsure whether their injury meets the criteria for whole person impairment or if the insurer’s assessment appears to be based on incorrect clinical standards.
Next Steps
Medical assessment disputes in NSW CTP claims require careful attention to both medical evidence and legal procedures. In regional areas, claimants may face additional hurdles in accessing specialist services, making it essential to act promptly and seek independent assessments. If you are involved in a medical assessment dispute, contact LegalAdvice.com.au to discuss your circumstances. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.