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).
If you have been involved in a motor accident in Greater Sydney and are disputing a medical assessment conducted under the Compulsory Third Party (CTP) insurance scheme, you are not alone. Disputes often arise when a medical practitioner’s assessment of your injury does not align with your ongoing symptoms or treatment needs, particularly in relation to whole person impairment (WPI) or the presence of a threshold injury. These disputes are managed through the Motor Accident Injuries Act 2017 (MAIA) and the framework provided by the State Insurance Regulatory Authority (SIRA). The process is designed to ensure assessments are independent, evidence-based and consistent with the Motor Accident Guidelines. In Greater Sydney, claimants must understand how SIRA’s processes work, what evidence is needed, and what steps to take if a decision is not accepted.
The Role of SIRA and the Personal Injury Commission in Medical Disputes
SIRA oversees the CTP scheme in New South Wales and administers the Personal Injury Commission (PIC), which handles formal disputes over medical assessments. If you disagree with a medical assessment, you may apply to the PIC for a review. The PIC is not a court, but it has the authority to review and, if necessary, overturn a medical assessment made under the CTP scheme. The process begins by requesting a review of the assessment, which must be done within a timeframe that depends on the nature of the dispute and whether the assessment was made by a treating medical practitioner or an independent medical examiner.
SIRA’s guidelines state that medical assessments must be conducted by qualified medical practitioners who follow the Motor Accident Guidelines, which set out the clinical standards for assessing injuries such as whiplash, back injuries, and psychological conditions. If your assessment was not conducted in accordance with these standards, or if it failed to account for objective clinical signs, you may have grounds for a dispute. The PIC will assess whether the assessment was reasonable, supported by evidence, and consistent with accepted medical practice.
Practical Steps to Prepare for a Medical Assessment
To prepare effectively for a medical assessment, you must gather and organise evidence that supports your claim of ongoing injury. This includes:
- A complete record of all medical treatment since the accident, including appointments with your general practitioner, specialists, physiotherapists, and mental health professionals.
- Copies of all diagnostic reports, such as MRI scans, X-rays, and nerve conduction studies, particularly those showing structural changes or neurological signs.
- A daily diary of symptoms, including pain levels, functional limitations, and any impact on work, household duties, or social activities.
- A written statement from a treating medical practitioner outlining the nature and duration of your symptoms, and how they relate to the accident.
- Evidence of any changes in income or capacity to work, such as a letter from your employer or a record of reduced hours.
It is essential to provide this information to your insurer or claims manager before the assessment, as it helps ensure the medical practitioner has a full picture of your condition. Failure to provide timely evidence may result in the assessment being based on incomplete information, which can weaken your case.
Common Pitfalls to Avoid in Greater Sydney Claims
Many claimants in Greater Sydney face challenges due to misunderstandings about the CTP process. One common mistake is assuming that a medical assessment must be accepted without challenge. This is not the case. If you believe the assessment underestimates your injury or fails to recognise a neurological sign such as a positive reflex or sensory change, you can formally dispute it. However, a dispute does not guarantee a different outcome. The PIC will assess whether the original assessment was reasonable, not whether it matches your personal view of your condition.
Another pitfall is waiting too long to seek a review. While there is no fixed deadline for applying to the PIC, delays can affect the strength of your case, particularly if new medical evidence emerges later. It is best to initiate a dispute as soon as you become aware of a discrepancy between your symptoms and the assessment. Also, avoid making statements to insurers or medical practitioners that contradict your medical records, as these can be used to challenge your credibility.
What to Expect During a PIC Medical Dispute Review
When you apply to the PIC for a review, your case will be assigned to a medical assessor who will examine the evidence, including your medical history, treatment records, and the original assessment. You may be asked to attend a new medical assessment, which will be conducted independently and may involve a specialist in your injury type, such as a spinal surgeon or neuropsychologist.
The review process typically takes several weeks, and you will be notified of the outcome in writing. If the PIC upholds the original assessment, you may still request a further review or consider whether to pursue a common law damages claim, but only if you meet the threshold for a serious injury. If the PIC finds that the original assessment was incorrect, it will issue a revised assessment, which may result in increased entitlements to treatment and care benefits, weekly payments, or damages.
When to Seek Independent Advice
Medical assessment disputes are complex and often hinge on technical medical and legal standards. While you are not required to have a solicitor to make a dispute, it is strongly advisable to seek independent legal advice before proceeding. A solicitor can help you understand whether your injury meets the criteria for a threshold injury, whether your WPI has been correctly assessed, and whether a dispute is likely to succeed.
For example, a claimant in Sydney’s inner west was assessed as having a 5% WPI for a soft-tissue neck injury. After providing MRI evidence showing a disc bulge with nerve root compression and a positive neurological sign, the PIC reviewed the case and increased the WPI to 15%. This change led to a higher entitlement to weekly payments and treatment benefits. This example illustrates how strong medical evidence can influence a PIC review.
Next Steps: Requesting Contact About Your Circumstances
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