How SIRA funds treatment costs for aggravated pre-existing injuries in NSW CTP 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).
If a motor accident worsens a pre-existing injury, the NSW Compulsory Third Party (CTP) scheme may fund treatment costs. The key is proving the injury was aggravated by the crash. SIRA assesses claims based on medical evidence, the nature of the aggravation, and whether the treatment is directly related to the worsened condition. This article explains how SIRA evaluates such claims, what evidence is needed, and the practical steps to pursue funding.
Legal framework for pre-existing injury aggravation claims
Under the Motor Accident Injuries Act 2017, CTP claims cover treatment costs for injuries caused by a motor accident. However, pre-existing injuries are treated differently. SIRA will only fund treatment for an aggravated injury if:
- The pre-existing condition was already present before the accident
- The crash caused a measurable worsening of the injury
- The treatment is directly related to the aggravated condition
SIRA’s guidelines (available on their website) state that the aggravation must result in a new or increased impairment. For example, if a claimant had a pre-existing back injury and the crash caused a herniated disc that worsened their existing condition, treatment costs may be funded.
What evidence is needed to claim treatment costs?
To support a claim for aggravated pre-existing injury treatment, claimants must provide:
- Medical records showing the pre-existing injury and its worsening after the accident
- Accident reports detailing how the crash occurred
- Witness statements or photographs of the incident
- Doctor’s reports linking the treatment to the aggravated injury
- Receipts or invoices for treatment costs
SIRA requires clear evidence that the treatment is for the aggravated injury, not a new condition. For instance, if a claimant with a pre-existing knee injury requires surgery after the crash, the surgeon must confirm the procedure addresses the worsened condition.
How SIRA differentiates between aggravated pre-existing injuries and new injuries
SIRA distinguishes between treatment for an aggravated pre-existing injury and new injuries by assessing:
- Medical evidence, Whether the injury worsened due to the crash
- Clinical signs, Such as increased pain, reduced mobility, or new neurological symptoms
- Cause and effect, Whether the crash directly caused the aggravation
For example, a claimant with a pre-existing ankle sprain who develops chronic instability after a crash may qualify for treatment funding. However, if the crash caused a new fracture unrelated to the pre-existing injury, the treatment would be funded under the new injury category.
Practical steps and time limits
Claimants should notify SIRA of their intention to claim treatment costs within 52 weeks of the accident. While the 52-week limit applies to certain benefits, treatment costs for aggravated injuries may be funded beyond this period if the injury is severe. However, delays can jeopardize claims, so prompt action is essential.
If SIRA disputes the claim, claimants can request a review or seek independent medical opinions. It’s important to note that SIRA’s decisions are not binding unless challenged through the formal process.
When to seek legal advice
Navigating SIRA’s assessment process can be complex. Legal professionals can help claimants:
- Interpret SIRA guidelines
- Challenge incorrect decisions
- Ensure all evidence is properly submitted
Seeking advice early can prevent claimants from missing critical deadlines or misrepresenting their injuries.
Example of an aggravated pre-existing injury claim
Consider a claimant with a pre-existing herniated disc who experiences increased pain and nerve symptoms after a car crash. A doctor confirms the crash caused a new disc protrusion that worsened the existing condition. SIRA would fund treatment for the aggravated injury, including physiotherapy and specialist consultations, as the treatment is directly related to the worsened condition.
Next steps for claimants
If you believe your treatment costs are related to an aggravated pre-existing injury, gather all relevant evidence and submit a claim to SIRA. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.