Understanding 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).
A medical assessment dispute arises when a claimant disagrees with the assessment of their injury by a medical practitioner appointed under the Compulsory Third Party (CTP) insurance scheme in New South Wales. This commonly occurs when the insurer’s doctor or the Personal Injury Commission (PIC) assesses the claimant’s injury as less severe than the claimant believes it to be, particularly in relation to pain, functional loss, or impairment. These disputes are not uncommon in Greater Sydney, where motor accidents involving pedestrians, cyclists, and passengers are frequent. The dispute may relate to the diagnosis, the degree of impairment, or whether the injury meets the threshold for damages under the Motor Accident Injuries Act 2017.
The Legal Framework: How Disputes Are Managed in NSW
Under the Motor Accident Injuries Act 2017, medical assessments are conducted by qualified medical practitioners, often nominated by the insurer or the Personal Injury Commission (PIC). The PIC is the independent body responsible for resolving disputes in CTP claims, including those involving medical assessments. The Motor Accident Injuries Regulation 2017 and the Motor Accident Guidelines provide the framework for these assessments, including the criteria for determining whole person impairment (WPI) and whether an injury qualifies as a threshold injury.
If a claimant disagrees with a medical assessment, they may request a review by the PIC. The PIC has the authority to order a new assessment, review the evidence, and issue a determination. The process is governed by procedural fairness and must be completed within a reasonable timeframe, though no fixed deadline is set by law. The claimant must provide all relevant medical evidence to support their position.
Practical Steps and Evidence That Matter
To challenge a medical assessment, a claimant should first obtain a copy of the assessment report and any supporting medical records. This includes records from treating medical practitioners, imaging reports (such as MRI or CT scans), and documentation of pain, loss of function, and treatment outcomes. Photographs of injuries, accident scene details, and witness statements may also be useful.
The claimant should notify the insurer in writing of their disagreement with the assessment, specifying the grounds for dispute. It is important to keep a record of all correspondence. The insurer may then refer the matter to the PIC for review. The PIC will assess whether the assessment was conducted in accordance with the Motor Accident Guidelines, including whether the practitioner followed the correct process for evaluating impairment and functional capacity.
Real-World Examples from Greater Sydney
In one example from Sydney’s Inner West, a pedestrian was struck by a car at a crosswalk near the Sydney Opera House. The claimant sustained a whiplash injury and reported ongoing neck pain and restricted movement. The insurer’s medical practitioner assessed the injury as a minor soft-tissue injury with no significant impairment. The claimant, however, had ongoing pain and was unable to return to full-time work. The claimant obtained a second opinion from an independent specialist who documented neurological signs consistent with a spinal nerve-root injury. The PIC reviewed the evidence and found that the injury met the definition of a threshold injury under the Motor Accident Guidelines, as it involved neurological signs beyond simple radiculopathy. The PIC ordered a new assessment, which resulted in a higher WPI rating and eligibility for damages.
In another case from the Northern Beaches, a cyclist sustained a shoulder injury in a collision with a car at a roundabout in Manly. The insurer’s doctor assessed a 5% WPI, but the claimant’s treating physiotherapist and orthopaedic surgeon provided evidence of a rotator cuff tear and functional loss. The PIC reviewed the MRI and clinical findings and determined that the injury was more severe than initially assessed. The PIC directed the insurer to pay treatment and care benefits and to reconsider the claim for damages.
When to Seek Advice and How to Navigate the Process
Medical assessment disputes can be complex and time-consuming. The claimant should not assume that a dispute will automatically result in a changed outcome. The PIC’s determination is based on the evidence, not on the claimant’s subjective experience alone. However, a well-documented case with supporting medical evidence significantly improves the chances of a favourable review.
If the PIC’s review does not resolve the dispute, the claimant may consider applying to the NSW Civil and Administrative Tribunal (NCAT) for a determination. This process is available for disputes about medical assessments, treatment and care benefits, and weekly income payments. The claimant must file an application within the applicable time limits, which are generally 12 months from the date of the insurer’s decision.
It is advisable to seek independent legal or medical advice early in the process. A solicitor experienced in CTP claims can help identify gaps in the evidence, prepare submissions, and represent the claimant before the PIC or NCAT. The claimant should not alter or fabricate medical records, but they should ensure that all records are complete and up to date.
Next Steps: What You Should Do Now
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