How SIRA resolves medical assessment disputes in NSW CTP claims
If you're disputing a medical assessment for a NSW Compulsory Third Party (CTP) claim, SIRA has specific rules to resolve the issue. SIRA assesses whether the medical evidence supports the claimant’s injuries and whether the injuries meet the threshold for compensation. This process applies equally in rural and remote areas, though claimants in these regions may face unique challenges in accessing medical records or specialist opinions.
Key SIRA rules for medical disputes
SIRA evaluates medical assessments based on the Motor Accident Guidelines and the Motor Accident Injuries Act 2017. A medical dispute arises when there’s disagreement about:
- Whether the injury meets the threshold injury definition (e.g., soft tissue injuries with neurological signs);
- The whole person impairment rating;
- The treatment and care benefits needed;
- The weekly income loss calculation.
SIRA’s internal review process allows claimants to challenge a medical assessment. This involves submitting additional evidence, such as:
- Updated medical records;
- Second opinions from registered medical practitioners;
- Evidence of ongoing treatment.
Rural and remote considerations
In rural and remote NSW, claimants may need to:
- Seek medical opinions through telehealth or regional clinics;
- Face delays in accessing specialist assessments;
- Use alternative evidence like work records or witness statements.
SIRA acknowledges these challenges but requires all claimants to follow the same evidentiary standards. For example, a claimant in a remote area must still provide medical records showing the injury’s impact on daily activities.
Steps to take when disputing a medical assessment
- Review the medical report: Ensure it clearly links the injury to the accident and meets the threshold injury definition. If the report lacks detail, request a revised assessment.
- Submit additional evidence: Provide updated medical records, work records, or evidence of treatment. For example, if a claimant’s injury affects their ability to work, income records are critical.
- Request an internal review: SIRA allows claimants to formally challenge a medical assessment. This must be done in writing within 28 days of receiving the medical report. The review considers whether the evidence supports the claimant’s injuries.
- Seek independent medical advice: If the dispute continues, consult a medical practitioner familiar with SIRA’s guidelines. They can help clarify whether the injury meets the threshold for compensation.
Time limits and when to seek advice
SIRA must resolve medical disputes within 28 days of receiving the claimant’s request for review. If the dispute involves a threshold injury, the 52-week statutory benefit period may apply. Claimants should act quickly to:
- Avoid missing deadlines;
- Ensure medical evidence is up-to-date;
- Seek legal advice if the dispute escalates.
Example of a rural medical dispute
A claimant in a remote NSW town sustains a soft tissue injury in a car accident. Their initial medical report states the injury does not meet the threshold for compensation. The claimant disputes this by providing:
- A second opinion from a regional physiotherapist;
- Evidence of ongoing pain and limited mobility;
- Work records showing reduced hours.
SIRA reviews the evidence and may reclassify the injury as a threshold injury, allowing the claimant to receive benefits. This example shows how rural claimants can challenge medical assessments using available resources.
When to seek legal advice
If the medical dispute involves complex issues like whole person impairment or lifetime care needs, legal advice may be necessary. A solicitor can help:
- Navigate SIRA’s internal review process;
- Challenge decisions based on legal grounds;
- Ensure all evidence meets the required standard.
Next steps
CTP entitlements depend on the accident date, injury type, and claim history. If you’re facing a medical assessment dispute, take action promptly. Complete the quick, no obligation enquiry form to request contact about your circumstances.