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).
If you're injured in a motor accident in Armidale and disagree with a medical assessment from your CTP insurer, you're not alone. Medical disputes are common in claims under the Motor Accident Injuries Act 2017. This article explains how SIRA handles such disputes, what evidence you need, and steps to resolve disagreements.
Common Medical Assessment Disputes
CTP insurers often dispute the severity of injuries, the need for ongoing treatment, or the link between the accident and your condition. Common issues include:
- Disagreements over whether injuries meet the 'threshold injury' definition
- Disputes about the necessity of specific treatments
- Conflicts over the impact of injuries on daily life
- Challenges to the accuracy of medical reports
These disputes often arise when insurers question the credibility of medical opinions or the relevance of treatment plans.
How SIRA Handles Medical Disputes
SIRA (State Insurance Regulatory Authority) oversees the CTP claims process in NSW. When a dispute arises:
- The insurer must provide a medical assessment within 28 days of receiving your claim
- You can request a review of the assessment by SIRA
- SIRA may seek a second medical opinion if there's a disagreement
- The final decision is based on the 'Medical Assessment Guidelines' and the 'Motor Accident Guidelines'
SIRA's role is to ensure assessments are fair and based on medical evidence, not financial considerations.
Steps to Resolve a Medical Dispute
If you disagree with an assessment, take these steps:
- Request a written copy of the medical report
- Gather evidence supporting your case, such as:
- Detailed medical records
- Statements from healthcare professionals
- Evidence of how injuries affect your daily life
- Any previous assessments or treatment plans
- Submit a formal dispute to SIRA within 28 days of receiving the assessment
- Consider seeking independent medical advice if needed
Evidence Required to Challenge an Assessment
To successfully challenge a medical assessment, you'll need:
- A clear link between the accident and your injuries
- Medical evidence showing the injury meets the threshold injury definition
- Documentation of treatment and recovery progress
- Evidence of how the injury impacts your ability to work or live independently
SIRA will assess whether the evidence supports a different conclusion than the initial assessment.
Time Limits and Dispute Options
You must submit a dispute to SIRA within 28 days of receiving the medical assessment. If you're unsatisfied with the outcome:
- You can request a review by the Personal Injury Commission (PIC)
- You may need to seek independent medical evidence through a court or tribunal
- You can also request a second opinion from a medical expert
Note that disputes don't guarantee a change in the assessment. SIRA must be convinced the original decision was incorrect.
When to Seek Advice
Medical disputes can be complex. Consider consulting a solicitor if:
- You're unsure how to challenge the assessment
- You need help gathering evidence
- You want to understand your options for dispute resolution
- You're concerned about time limits
A lawyer can help you navigate the process and ensure your rights are protected.
Final Steps
If you're in Armidale and facing a medical assessment dispute, take action within the 28-day window. Gather all relevant evidence and consider seeking independent medical advice. Remember, every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.