Common 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).
Injured people in Greater Sydney often seek clarity on why their medical assessment results differ from their symptoms, treatment progress or expectations. The most frequent disputes involve the assessment of injury severity, the determination of whole person impairment (WPI), and the classification of injuries as threshold or non-threshold under the Motor Accident Injuries Act 2017. These disputes commonly arise when a medical practitioner’s report suggests a lower WPI than the claimant believes is warranted, or when an injury is categorised as a threshold injury despite ongoing functional limitations. Disputes may also occur when a claimant’s symptoms persist beyond the 52-week period for statutory benefits, or when a medical report fails to acknowledge neurological signs that support a claim for damages.
How SIRA handles medical assessment disputes
The State Insurance Regulatory Authority (SIRA) oversees the resolution of medical assessment disputes under the Motor Accident Injuries Act 2017. When a dispute arises, the claimant may request an internal review of the assessment through the insurer’s claims process. If the dispute remains unresolved, the claimant may apply to the Personal Injury Commission (PIC) for a medical dispute resolution. The PIC is the independent body responsible for reviewing medical assessments and making binding decisions on issues such as WPI, injury classification, and the presence of threshold injuries. The PIC’s decisions are made based on medical evidence, the Motor Accident Guidelines, and the legal framework under the MAIA.
Key questions injured people should ask about their medical assessment
Injured people in Greater Sydney should ask the following questions to better understand their medical assessment: Was the assessment conducted by a qualified medical practitioner with expertise in injury assessment, as required under SIRA guidelines? Does the report clearly reference the Motor Accident Guidelines, particularly regarding the definition of a threshold injury and the criteria for radiculopathy or spinal nerve-root injury? Is there a documented explanation for why a particular injury was not classified as a threshold injury, or why a WPI percentage was assigned at a certain level? Did the medical practitioner consider all relevant symptoms, including persistent pain, loss of function, and impact on daily activities? If the assessment was based on a single visit, was there sufficient clinical evidence to support a conclusion about long-term impairment? These questions help identify whether the assessment was thorough, consistent with the law, and properly supported by evidence.
How medical assessment disputes affect compensation outcomes
A medical assessment dispute can significantly affect the type and amount of compensation available. If an injury is classified as a threshold injury, the claimant may be limited to treatment and care benefits and weekly income payments for up to 52 weeks after the accident, unless the injury is later determined to be a non-threshold injury. If the assessment determines a WPI of 10% or more, the claimant may be eligible to claim damages for pain and suffering, loss of enjoyment of life, and future care needs. A dispute that results in a higher WPI or a change in injury classification may therefore increase the claimant’s entitlement to damages. Conversely, a dispute that confirms a lower WPI or a threshold injury classification may restrict access to damages. The outcome depends on the strength and consistency of the medical evidence presented.
SIRA guidelines and the medical dispute resolution process
SIRA’s guidelines require that medical assessments be conducted by a qualified medical practitioner who has not previously treated the claimant, to ensure impartiality. The assessment must be based on a review of all available medical records, including imaging, clinical notes, and functional capacity testing. The Motor Accident Guidelines set out the criteria for determining whether an injury constitutes a threshold injury, including the requirement for radiculopathy to be confirmed by objective clinical signs. The PIC process allows the claimant to submit additional medical evidence, including second opinions, and to request a review of the assessment. The PIC must make a decision within 60 days of receiving a dispute application, and the decision is binding on the insurer and the claimant. The process does not guarantee a changed outcome, but it provides a formal mechanism to challenge assessments that appear inconsistent with the evidence or the law.
Practical steps and evidence that matter in a medical dispute
To support a medical assessment dispute, claimants should gather and preserve the following evidence: all medical records from the accident date to the present, including treatment notes, imaging reports, and rehabilitation progress reports; a written summary of symptoms and functional limitations, including how the injury affects work, household tasks, and social activities; a list of any witnesses who observed the claimant’s condition; and copies of correspondence with the insurer, including any internal review decisions. Photographs of injuries, such as visible swelling or scarring, may also be useful. It is important to submit all evidence to the insurer or PIC as soon as possible, as delays may affect the outcome. The claimant should not alter or delete any medical records, as this may compromise the integrity of the claim.
Time limits and when to seek advice
There is no fixed time limit for initiating a medical dispute under the MAIA, but delays may affect the ability to obtain timely compensation. The insurer must respond to a dispute request within 28 days, and the PIC must decide within 60 days of receiving the application. If a claimant has not received a response within 28 days, they may request a review of the insurer’s inaction. It is advisable to seek advice from an independent legal or medical professional before submitting a dispute, particularly if the claim involves a complex injury or a history of prior medical conditions. The claimant should not assume that a dispute will result in a higher WPI or a change in injury classification, as the PIC’s decision is based on the evidence and the law, not on the claimant’s expectations.
Hypothetical example: A claimant’s experience in Sydney
A 42-year-old Sydney office worker was involved in a rear-end collision in the Eastern Suburbs in August 2025. She reported neck and back pain, dizziness, and difficulty concentrating. Her treating doctor diagnosed a soft-tissue injury and referred her for physiotherapy. After 18 months, her symptoms persisted, including chronic pain and reduced mobility. A medical assessment conducted by the insurer’s appointed doctor classified her injury as a threshold injury and assigned a WPI of 5%. The claimant disputed this, arguing that MRI scans showed nerve root compression and that her functional limitations were not reflected in the assessment. She submitted additional medical evidence, including a second opinion from a specialist neurologist, and applied to the PIC for a medical dispute resolution. The PIC reviewed all evidence and concluded that the injury met the criteria for a non-threshold injury due to the presence of objective neurological signs. The claimant was subsequently allowed to claim damages for pain and suffering and future care needs.
Next steps
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