What the PIC Requires to Resolve Disputes Over Pedestrian Crossing Injuries
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).
If you were injured as a pedestrian crossing at a marked crossing in NSW, the CTP insurer (PIC) will assess your claim based on specific rules. Disputes often arise over whether injuries meet the threshold for benefits or if the accident circumstances support a claim. Understanding what evidence the PIC requires is critical to resolving these disputes effectively.
NSW CTP Rules Behind Pedestrian Crossing Claims
Under the Motor Accident Injuries Act 2017, CTP insurers must provide benefits for injuries caused by motor vehicles. For pedestrian claims, the PIC evaluates whether the injury meets the 'threshold injury' definition in the Motor Accident Guidelines. This includes soft tissue injuries, fractures, and neurological conditions. Key factors include:
- Accident location: The incident must occur at a marked pedestrian crossing. Unmarked crossings or private property may require additional evidence.
- Injury type: Soft tissue injuries (e.g., whiplash) must meet specific clinical criteria, such as spinal nerve-root injuries producing neurological signs. Radiculopathy requires specified clinical signs.
- Fault and contributory fault: While CTP claims are typically no-fault, the PIC may consider contributory fault if the pedestrian breached road rules.
Evidence the PIC Requires in Disputes
To resolve disputes, the PIC will scrutinize evidence such as:
- Medical records: Detailed documentation from a medical practitioner confirming the injury, its cause, and treatment. This includes imaging reports and clinical notes.
- Accident reports: Police reports or statements from witnesses confirming the incident occurred at a marked crossing.
- Photographs and videos: Visual evidence of the crossing, traffic conditions, and vehicle positioning.
- Witness statements: Accounts from bystanders or drivers confirming the pedestrian’s actions and the accident sequence.
- Income and employment records: To assess lost wages or future earning capacity if the injury affects work.
For example, if a pedestrian claims soft tissue injuries but medical records lack specific neurological signs, the PIC may dispute the claim. In such cases, a second medical opinion from a SIRA-approved provider may be required.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident, unless the injury is not immediately apparent. If the injury is a 'threshold injury' (e.g., a minor sprain), benefits are generally limited to 52 weeks. After this period, the PIC may argue that benefits should stop unless the injury meets higher impairment thresholds.
Disputes can be resolved through:
- Internal review: The PIC may reassess the claim based on new evidence or a medical review.
- Personal Injury Commission (PIC) review: If the claimant disagrees with the PIC’s decision, they can request a review by the PIC. This process involves a medical expert assessing the injury’s severity.
- Legal challenge: If the claimant believes the PIC’s decision is incorrect, they may seek legal advice to challenge it through the NSW Civil and Administrative Tribunal (NCAT).
Practical Steps for Claimants
To meet the PIC’s expectations, claimants should:
- Seek immediate medical attention to document the injury and its cause.
- Preserve accident details, including photos, witness contact information, and traffic camera footage.
- Submit the claim promptly within the 52-week timeframe.
- Provide clear evidence of the injury’s impact, such as medical reports and income loss documentation.
- Engage with the PIC’s review process to address disputes, such as by requesting a medical assessment.
When to Seek Legal Advice
If the PIC denies the claim or disputes the level of benefits, it may be necessary to consult a solicitor. Legal advice can help challenge the PIC’s decision, especially if:
- The claimant believes the PIC misinterpreted the injury’s severity.
- The claimant has a pre-existing condition that complicates the assessment.
- The PIC refuses to consider new evidence or a medical review.
Summary of PIC Expectations
The PIC requires clear evidence that the pedestrian injury occurred at a marked crossing and meets the threshold injury definition. Disputes often hinge on medical documentation, accident circumstances, and adherence to time limits. By gathering the right evidence and engaging with the PIC’s review process, claimants can improve their chances of resolving disputes.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.