How Insurers Assess Pre-existing Injury Aggravation in NSW
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
When a motor accident in Armidale, NSW, worsens a medical condition that existed before the crash, the claim for compensation is governed by the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. Insurers assess whether the accident caused a significant worsening of the pre-existing injury, not a new injury. This assessment is critical because it determines whether the claimant is entitled to treatment and care benefits, weekly income payments, or damages under the CTP scheme. The insurer must consider whether the accident caused a material increase in the severity of the pre-existing condition, not merely a continuation of pre-accident symptoms.
What Evidence Supports a Claim of Aggravation?
To establish that a pre-existing injury was aggravated by a motor accident, claimants must provide medical evidence showing a measurable change in condition following the crash. This includes:
- A detailed medical record from a treating practitioner documenting the pre-accident condition and any change in symptoms, function, or diagnosis after the accident.
- An independent medical assessment, often conducted under the Motor Accident Guidelines, to determine if the injury has worsened and whether the accident was a significant contributing factor.
- Objective clinical findings such as new imaging results (e.g. MRI or X-ray), nerve conduction studies, or changes in physical function that were not present before the accident.
Insurers may rely on a medical report that attributes the current symptoms to the pre-existing condition alone, particularly if there is no objective evidence of a new or worsened injury. The claimant must demonstrate that the accident caused a clinically significant change, not just a natural progression of the pre-existing condition.
How Insurers Decide and When They May Challenge a Claim
Insurers in Armidale, like elsewhere in NSW, are required to assess claims under the Motor Accident Injuries Act 2017 and the SIRA Motor Accident Guidelines. They may accept a claim for treatment and care benefits if the injury is not a threshold injury, or they may reject a claim for damages if they determine the injury was not caused by the accident or if the pre-existing condition was the primary cause of the current symptoms.
Common insurer decisions include:
- Accepting treatment and care benefits but denying damages due to a lack of threshold injury.
- Denying weekly income payments if the claimant is not unable to work due to the accident.
- Challenging the causal link between the accident and the aggravation, particularly where the pre-existing injury was stable or mild before the crash.
If an insurer denies a claim or limits benefits, the claimant has the right to request an internal review within 28 days of receiving the decision. The insurer must respond within 28 days of the request. If the review does not result in a favourable outcome, the claimant may apply to the Personal Injury Commission for a medical dispute determination under the Motor Accident Injuries Act 2017.
Practical Steps After an Insurer Decision
If you have received a decision from your insurer in Armidale that you believe is incorrect, take the following steps:
- Obtain a copy of the insurer’s decision letter and any supporting medical reports.
- Request an internal review of the decision within 28 days.
- Gather all medical records, including pre-accident and post-accident assessments, imaging, and treatment notes.
- Seek a second medical opinion from a specialist who has experience in motor accident injury assessments.
- Apply to the Personal Injury Commission for a medical dispute determination if the internal review is unsuccessful.
A medical dispute under the Commission’s process allows for an independent medical review to determine whether the injury was caused or significantly aggravated by the accident. The Commission may order a new assessment or accept a report from a medical practitioner approved under the Motor Accident Guidelines.
Hypothetical Example: Aggravation of a Pre-existing Back Condition
A 45-year-old resident of Armidale had a history of chronic lower back pain due to degenerative disc disease, which had been stable for five years. After a minor rear-end collision in 2024, they reported increased pain, reduced mobility, and new neurological symptoms including numbness in the left leg. An MRI taken two months post-accident showed a new herniation at L4-L5, not present before the crash. The treating neurologist concluded that the accident was a significant contributing factor to the new injury and the worsening of the pre-existing condition. The insurer initially denied a claim for damages, arguing the symptoms were attributable to the pre-existing condition. After a medical dispute application, the Personal Injury Commission accepted the medical evidence and determined the injury was aggravated by the accident. The claimant was awarded treatment and care benefits and was eligible to claim damages.
Time Limits and the Importance of Acting Promptly
There are time limits that apply to CTP claims in NSW. While the claim for treatment and care benefits can generally be made at any time, a claim for damages must be made within three years of the accident date. Failure to meet this deadline may prevent a damages claim from being heard, even if the injury was aggravated by the accident. Additionally, a claim for an internal review must be made within 28 days of receiving the insurer’s decision.
When to Seek Independent Legal Advice
Every claim depends on its own facts. The legal and medical evidence required to prove aggravation of a pre-existing injury is complex and must be assessed under the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines. Insurers may rely on medical reports that downplay the impact of the accident or attribute symptoms solely to pre-existing conditions. If you believe your insurer has made an incorrect decision regarding a pre-existing injury, it is important to seek independent advice before finalising any response.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.