What SIRA Prioritizes in Pedestrian Crossing Claims
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 pedestrian is injured at a marked crossing in NSW, the claim is governed by the Motor Accident Injuries Act 2017 and assessed by the State Insurance Regulatory Authority (SIRA). SIRA evaluates claims based on three core factors: the nature of the injury, the evidence supporting the claim, and compliance with CTP scheme rules. For disputes, SIRA focuses on whether the injury meets the 'threshold injury' definition under the Motor Accident Guidelines and whether the claimant has followed the correct process.
Key Factors SIRA Considers
SIRA prioritizes:
- Medical evidence showing a diagnosed injury, including imaging and clinical notes.
- Accident circumstances such as traffic signals, road conditions, and witness statements.
- Compliance with CTP rules, including timely notification of the insurer.
Disputes often arise when injuries are classified as 'soft tissue' (e.g., whiplash) or 'threshold injuries' (e.g., minor fractures). SIRA requires specific clinical signs for radiculopathy claims and may challenge claims where injuries are deemed non-impairing.
Practical Steps for Claimants
To support your claim:
- Document the accident with photos, witness details, and a police report.
- Seek medical attention immediately and ensure records are detailed.
- Notify your insurer within 52 weeks of the accident.
If your injury is classified as a 'threshold injury' (e.g., a minor sprain), benefits may be limited after 52 weeks under the Act. SIRA may dispute claims where the injury does not meet the threshold definition.
Dispute Resolution and Time Limits
Disputes over injury severity or claim validity can be resolved through SIRA's internal review process. If your claim is challenged, you may request a medical review by a SIRA-appointed specialist. Note that a challenge does not guarantee a changed decision.
Time limits are critical: claims must be submitted within 52 weeks of the accident. Delays may result in lost benefits, even if the injury is valid.
When to Seek Legal Advice
Consult a solicitor if:
- Your injury is contested as not meeting the threshold.
- You receive a 'no claim' decision.
- You need to challenge a medical assessment.
A lawyer can help navigate SIRA's requirements and ensure your claim aligns with the Motor Accident Guidelines.
Example: Soft Tissue Injury Dispute
A pedestrian hit at a crossing claims whiplash. SIRA may dispute the injury if:
- Medical records lack specific clinical signs.
- The injury is classified as 'soft tissue' without neurological impairment.
- The claimant fails to notify the insurer within 52 weeks.
In such cases, SIRA may limit benefits to the 52-week statutory cap.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.