How Insurers Evaluate Liability for Pre-existing Injury Aggravation
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 medical condition, insurers must determine whether the accident caused or aggravated the injury. Under NSW CTP rules, the key question is whether the accident contributed to the injury beyond its original state. SIRA guidelines state insurers must assess whether the accident caused or worsened the condition, considering medical evidence and the nature of the incident.
Legal Framework for Pre-existing Injury Claims
The Motor Accident Injuries Act 2017 governs CTP claims. Insurers must evaluate whether the accident caused or aggravated the injury, not just whether the claimant had a prior condition. SIRA’s guidelines clarify that insurers cannot assume a pre-existing injury is unrelated unless medical evidence proves otherwise. For example, if a claimant with a history of back pain experiences increased symptoms after a collision, the insurer must assess whether the accident caused the worsening.
Practical Steps to Support Your Claim
To demonstrate that an accident aggravated a pre-existing injury, claimants should:
- Gather medical records showing the pre-existing condition and its progression
- Obtain a medical opinion linking the accident to the worsened injury
- Document the accident details, including how the injury was aggravated
- Provide evidence of how the aggravation impacts daily life or mobility
Insurers often request independent medical assessments to evaluate the connection between the accident and the injury. Claimants should ensure their medical records clearly show the pre-existing condition and how the accident caused a measurable worsening.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident if only threshold injuries are involved. However, if the aggravation results in a new or worsened injury, the 52-week limit may not apply. Claimants should act quickly to preserve evidence and meet deadlines. If an insurer disputes liability, claimants can request a review under the Motor Accident Injuries Act 2017 or seek independent legal advice.
Example of Aggravation Assessment
Consider a claimant with a pre-existing herniated disc who experiences increased pain and nerve damage after a car accident. SIRA guidelines require insurers to assess whether the accident caused the nerve damage or worsened the existing condition. If medical evidence shows the accident caused new nerve damage, the claimant may be entitled to additional benefits.
When to Seek Legal Advice
Insurers may challenge claims by arguing the injury was unrelated or by disputing the extent of the aggravation. Claimants should seek legal advice if:
- The insurer denies liability based on pre-existing conditions
- Medical evidence is unclear or contested
- The claimant is unsure how to prove the aggravation
Legal professionals can help claimants navigate SIRA guidelines, challenge unfair denials, and ensure they receive compensation for injuries worsened by a motor accident.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.