How Insurers Assess Liability in Medical Assessment Disputes
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).
Insurers in New South Wales assess liability in medical assessment disputes by evaluating medical evidence against the Motor Accident Injuries Act 2017 (MAIA) and SIRA guidelines. This process determines whether a claimant qualifies for statutory benefits or common law damages. In Newcastle and Hunter, claimants must understand how insurers interpret medical reports, treatment records, and injury thresholds to resolve disputes.
Key Factors in Insurer Liability Assessments
Insurers consider several factors when assessing medical evidence, including:
- Medical reports from registered practitioners detailing injury severity and treatment.
- SIRA guidelines on threshold injuries, which define soft tissue injuries eligible for statutory benefits.
- Clinical signs such as radiculopathy or spinal nerve-root injuries, as specified in the Motor Accident Guidelines.
- Treatment records showing ongoing care needs beyond 52 weeks.
- Insurer's internal protocols for assessing injury severity and liability.
Insurers may dispute a claimant's injury classification if medical evidence does not meet SIRA's threshold criteria. For example, a claimant with a soft tissue injury requiring physiotherapy may be denied benefits if the insurer argues the injury does not meet the 'threshold injury' definition.
Medical Assessment Dispute Process (MADP)
When insurers dispute liability, claimants can request an internal review or escalate to the Personal Injury Commission (PIC). The MADP involves:
- Insurer's internal review of the medical assessment within 21 days.
- PIC medical dispute pathway if the insurer rejects the claim, involving a medical expert review.
- Dispute resolution through the PIC, which may order a fresh medical assessment.
Claimants should note that the PIC does not guarantee a changed decision. Insurers must demonstrate that the original assessment was incorrect or incomplete.
Practical Steps for Claimants
To challenge an insurer's liability assessment, claimants should:
- Request a copy of the insurer's medical assessment to understand their reasoning.
- Gather additional evidence, such as second opinions or updated treatment records.
- Submit a formal dispute request through the insurer's internal review process.
- Seek legal advice if the insurer refuses to reconsider the claim.
Insurers in Newcastle and Hunter often rely on SIRA's 'What You Can Claim' guidelines to determine benefits. Claimants must ensure their medical evidence clearly demonstrates injury severity and treatment needs.
Time Limits and Dispute Options
Claimants must act within strict time limits:
- 52 weeks for statutory benefits after an injury is classified as a threshold injury.
- 21 days for an insurer's internal review of a disputed claim.
- No set time limit for PIC dispute resolution, but delays may affect evidence collection.
If an insurer denies liability, claimants may also consider:
- Mediation through the PIC.
- Legal action if the insurer refuses to engage with the dispute process.
When to Seek Legal Advice
Claimants should consult a solicitor if:
- The insurer refuses to acknowledge a valid medical assessment.
- The claimant's injury exceeds the threshold injury definition.
- The insurer disputes liability without providing a clear rationale.
Legal professionals can help claimants navigate the complex interplay between medical evidence and insurer assessments, ensuring their rights under the MAIA are protected.
Next Steps
CTP entitlements depend on the accident date, injury classification, and claim history. To request contact about your circumstances, complete the quick, no obligation enquiry form.