How NSW CTP Insurers Assess Pre-existing Injury Aggravation
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).
If a motor accident worsens a pre-existing injury, insurers must determine whether the aggravation is a direct result of the crash. Under NSW law, claimants must prove the injury was 'aggravated' by the accident, not merely exacerbated by general life factors. Insurers evaluate medical evidence, the nature of the accident, and the timing of symptoms to assess liability. For example, if a person with a pre-existing back injury experiences new neurological symptoms after a car crash, the insurer will examine medical records to determine if the accident caused the worsening.
Key Legal Framework for Pre-existing Injury Claims
NSW CTP insurers rely on the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines to assess aggravation claims. The Act defines 'threshold injury' as a minor injury requiring treatment, but aggravation of a pre-existing injury may qualify for benefits regardless of severity. SIRA (State Insurance Regulatory Authority) advises that claimants must demonstrate a 'direct link' between the accident and the worsened condition. This often involves showing that the accident caused new or increased symptoms that would not have occurred without the incident.
Practical Steps for Claimants in Newcastle and Hunter
To support a claim, injured persons should:
- Gather comprehensive medical records detailing the pre-existing injury and its progression
- Document the accident date, location, and circumstances
- Obtain evidence of how the accident caused new or worsened symptoms
- Provide a medical opinion linking the aggravation to the crash
Insurers often request a specialist report from a medical practitioner to assess whether the injury was aggravated. For instance, if a cyclist with a pre-existing knee injury sustains a new ligament tear after a collision, the insurer will require evidence that the accident caused the tear rather than a degenerative condition.
Time Limits and Dispute Options
CTP insurers must respond to claims within 28 days of receiving all necessary documentation. If a claimant disagrees with a decision, they can:
- Lodge a written review with SIRA within 28 days
- Seek independent medical assessment
- Consult a solicitor to challenge the insurer's interpretation of the guidelines
Note that the 52-week limit for weekly income benefits applies only to 'threshold injuries' under the Act. Aggravation claims may extend beyond this period if the injury meets the threshold criteria.
Example of Aggravation Assessment
Consider a pedestrian with a pre-existing ankle injury who sustains a new fracture after a car accident. The insurer will assess:
- Medical records showing the original injury and its treatment
- Evidence of the accident causing the fracture
- Whether the fracture would have occurred without the crash
If the medical evidence confirms the accident caused the fracture, the claimant may be entitled to treatment benefits and income support.
When to Seek Legal Advice
Insurers may dispute claims by arguing the injury was not aggravated or by misinterpreting medical evidence. Claimants should seek legal assistance if:
- The insurer refuses to acknowledge the aggravation
- Medical reports are unclear or incomplete
- The claimant faces a time limit for lodging a review
Independent legal advice can help claimants understand their rights under the Motor Accident Injuries Act and ensure all evidence is properly presented.
Next Steps for Claimants
CTP claims involving pre-existing injuries require careful documentation and legal understanding. While insurers must assess claims based on medical evidence, claimants have the right to challenge decisions through formal review processes. For personalized guidance on your circumstances, complete the quick, no obligation enquiry form.