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).
Under New South Wales law, the 10% whole person impairment threshold determines whether injured claimants qualify for ongoing treatment funding under the Compulsory Third Party (CTP) scheme. This threshold is central to assessing whether a claimant’s injuries meet the criteria for long-term medical support. If your injuries result in a 10% or greater impairment rating, you may be eligible for treatment costs to be funded by the at-fault driver’s insurer. This article explains how the threshold works, what evidence is needed, and when to seek legal advice.
The 10% Impairment Threshold and Funding Rules
The 10% threshold is defined under the Motor Accident Injuries Act 2017 (MAIA) and applies to claims under the NSW CTP scheme. It means that only injuries resulting in a whole person impairment rating of 10% or more qualify for ongoing treatment funding. SIRA (State Insurance Regulatory Authority) assesses impairment ratings using the Motor Accident Guidelines, which outline clinical criteria for different injury types.
For example, a fractured wrist that requires surgery and results in limited arm function might be rated as 10% impairment. In such cases, the CTP insurer must cover the cost of ongoing treatment, including physiotherapy, specialist consultations, and medical equipment. If the impairment rating is below 10%, treatment costs are generally not funded, though some care may still be available under statutory benefits.
How SIRA Assesses Impairment for Funding
SIRA evaluates impairment ratings based on clinical evidence, including medical reports, imaging, and specialist opinions. The guidelines specify that a 10% rating requires a significant impact on daily activities, such as mobility, work capacity, or personal care. For instance, a claimant with a 10% impairment due to a spinal injury might need regular physiotherapy to maintain mobility, which would be funded under the CTP scheme.
Claimants must provide detailed medical records to support their impairment rating. This includes documentation of the injury’s severity, treatment received, and how it affects their ability to work or perform daily tasks. SIRA may also require a second opinion from a registered medical practitioner to confirm the rating.
Practical Steps for Claimants
To qualify for treatment funding, claimants must:
- Obtain a formal impairment rating from a medical practitioner
- Submit detailed medical records to SIRA
- Demonstrate that the injury meets the 10% threshold
- Provide evidence of ongoing treatment needs
For example, a cyclist injured in a car accident who undergoes a 10% impairment rating after months of rehabilitation would be eligible for funded treatment. However, a pedestrian with minor soft tissue injuries (e.g., a sprained ankle) that resolve within weeks would not qualify for long-term funding.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident, unless an extension is granted. If a claimant’s impairment rating is below 10%, they may still receive limited treatment benefits under the 52-week statutory benefits regime. However, funding for ongoing care typically stops after this period unless the impairment rating is 10% or higher.
If a claimant disputes a SIRA impairment rating, they can request a review or seek independent medical assessment. Legal advice may be necessary to challenge an adverse decision or ensure all evidence is properly submitted.
When to Seek Legal Advice
The 10% threshold is a critical legal test for treatment funding. Claimants should consult a solicitor if:
- Their impairment rating is disputed
- They need help gathering medical evidence
- They face a time limit for submitting a claim
- They want to challenge a decision to stop funding
A solicitor can help ensure that all legal requirements are met and that claimants understand their rights under the CTP scheme.
Summary of Key Points
- The 10% impairment threshold determines eligibility for ongoing treatment funding
- SIRA assesses ratings using clinical guidelines and medical evidence
- Claimants must submit detailed records to support their claim
- Funding stops after 52 weeks unless the impairment rating is 10% or higher
- Legal advice is recommended for disputes or complex cases
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