How to Resolve Disputes Over Pre-Existing Injuries in CTP Claims
If you sustained a motor accident on the Central Coast and your existing medical condition worsened as a result, you may be eligible for compensation under NSW's Compulsory Third Party (CTP) insurance scheme. This article explains how to challenge a claim rejection or limitation involving pre-existing injuries, referencing SIRA's guidance on claim assessments and dispute resolution processes.
Under the Motor Accident Injuries Act 2017 (MAIA), a 'threshold injury' includes soft tissue injuries and certain psychological conditions. If your existing condition deteriorated after the accident, you may still qualify for treatment and care benefits, weekly income payments, or damages if the worsening is significant enough to meet the injury threshold.
SIRA's Approach to Injury Aggravation Claims
SIRA evaluates whether a pre-existing injury has been aggravated by a motor accident using clinical evidence. The assessment focuses on whether the accident caused a measurable deterioration in your condition, not just a temporary increase in symptoms. Medical records must show a clear link between the accident and the worsening of your condition.
For example, if you had a pre-existing spinal condition and the accident caused new neurological symptoms such as numbness or weakness, this may support a claim. SIRA will review your medical records, specialist reports, imaging results, and treatment notes to determine if the injury meets the threshold for benefits.
Dispute Resolution Options on the Central Coast
If your claim is rejected or limited, you have formal options to challenge the decision. First, request an internal review from the CTP insurer within 28 days of their decision. The insurer must respond in writing within 60 days. If the review is unsatisfactory, you may apply to the Personal Injury Commission (PIC) for a review of the claim assessment.
The PIC will assess the medical evidence, review the insurer’s decision, and may request an independent medical opinion. For claims involving damages, the PIC will determine if the injury meets the threshold for compensation under the MAIA.
Evidence to Support Your Claim
To strengthen your case, gather the following evidence:
- Medical records showing your condition before and after the accident
- Specialist reports comparing your pre- and post-accident condition
- Imaging results (e.g., MRI scans) showing structural changes
- A statement from your treating medical practitioner explaining the worsening
- Accident reports, witness statements, and photographs of the scene
Prompt medical treatment and documentation of all appointments and communications with healthcare providers are crucial.
Time Limits and Next Steps
You must request an internal review within 28 days of the insurer’s decision. If you apply to the PIC, you have 12 months from the insurer’s decision to do so. These deadlines are strict and cannot be extended unless exceptional circumstances apply.
A dispute does not guarantee a change in the decision. The PIC may uphold the insurer’s original assessment or order a different outcome based on the evidence. The process can take several months, and you may need to attend a hearing or provide additional medical evidence.
If you are unsure whether your injury has been aggravated or if your claim has been rejected, seek independent legal advice. A solicitor with experience in CTP claims can help you understand your rights and guide you through the dispute process.
Hypothetical Example
A 52-year-old Central Coast resident with a history of degenerative disc disease experienced new and persistent sciatica, leg weakness, and a spinal nerve-root injury after a low-speed rear-end collision. Their treating neurologist confirmed the MRI changes were consistent with a new injury caused by the accident. The CTP insurer initially refused benefits, but after an internal review and a PIC review, the claimant was awarded treatment and care benefits and a reconsideration of the damages claim.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.