Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
When a medical assessment dispute arises in a NSW Compulsory Third Party (CTP) claim, insurers use a structured process to determine liability. This article explains how insurers assess medical evidence, referencing SIRA guidelines, and outlines steps injured claimants can take in Bathurst.
How Insurers Assess Liability in Medical Disputes
NSW CTP insurers evaluate medical evidence by considering whether the injury meets the legal threshold for compensation. Under the Motor Accident Injuries Act 2017, injuries must result in a 'threshold injury', a defined level of harm that includes soft tissue injuries, fractures, or neurological damage. Insurers rely on the Motor Accident Guidelines to assess whether a medical assessment supports this threshold.
For example, if a claimant presents with chronic back pain but no diagnosed spinal nerve-root injury, the insurer may dispute liability. SIRA’s guidelines specify that radiculopathy (nerve-related pain) requires clinical signs like reflex changes or sensory loss. Insurers also consider whether the injury is 'reasonably foreseeable' from the accident.
Practical Steps for Claimants in Bathurst
Injured claimants should ensure their medical records clearly document the injury’s connection to the accident. Key evidence includes:
- Detailed treatment plans from medical practitioners
- Independent assessments from accredited specialists
- Records linking symptoms to the accident date
Insurers may request additional assessments if they dispute the severity of the injury. Claimants should retain all medical correspondence and consider seeking a second opinion if their assessment is challenged.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident, though extensions may apply for complex cases. If an insurer disputes liability, claimants can:
- Request an internal review by the insurer
- Lodge a complaint with the Personal Injury Commission (PIC) within 28 days of the insurer’s decision
- Pursue mediation or legal action if the dispute remains unresolved
It’s important to note that disputing an insurer’s assessment does not guarantee a changed decision. The PIC will assess whether the insurer’s evaluation aligns with SIRA guidelines and medical evidence.
When to Seek Legal Advice
Medical disputes often involve complex legal and clinical interpretations. A solicitor can help claimants:
- Challenge an insurer’s refusal to accept a medical assessment
- Navigate the PIC’s dispute resolution process
- Ensure all evidence meets CTP scheme requirements
If your claim involves a psychological injury or contested medical opinion, legal assistance can help ensure your case is evaluated fairly.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.