Pre-existing injury aggravation, what the PIC expects in disputes (NSW-wide)
If a motor accident worsens a pre-existing injury, claimants must prove the aggravation to access compensation under NSW’s Compulsory Third Party (CTP) scheme. The Personal Injury Commission (PIC) evaluates claims by assessing medical evidence, the accident’s impact, and whether the injury was aggravated. This article explains what the PIC expects in disputes and how to navigate the process.
Key factors the PIC considers
- The PIC focuses on two main questions:
- Was the injury aggravated by the accident?* and
- What evidence supports this?* Key considerations include:
- Medical evidence: Doctors must document that the pre-existing injury worsened after the accident. This includes pre- and post-accident medical records, imaging, and specialist reports.
- Accident impact: The PIC assesses whether the accident caused a material change in the injury’s severity. For example, a pre-existing back injury that required minimal treatment might worsen to the point of needing surgery after an accident.
- Causation: Claimants must show a direct link between the accident and the aggravation. This often involves expert medical opinions explaining how the accident’s forces or trauma caused the worsening.
Proving aggravation: Evidence and documentation
To succeed, claimants must provide:
- Pre-accident medical records showing the existing injury and its history.
- Post-accident medical records detailing the worsened condition, including new symptoms, treatment plans, and prognosis.
- Accident reports or witness statements confirming the incident’s details.
- Expert opinions from medical practitioners or specialists confirming the aggravation.
For example, a claimant with a pre-existing knee injury that required occasional physiotherapy might need to show that the accident caused a tear or flare-up requiring surgery. Medical records must explicitly link the accident to the worsening.
Dispute resolution and internal review
If the PIC disputes the claim, claimants can request an internal review. The PIC’s guidelines state that disputes must be resolved through its internal medical dispute pathway, which involves:
- Medical expert review by a specialist appointed by the PIC.
- Written submissions from the claimant’s medical team and the PIC.
- Final decision by the PIC, which may uphold, amend, or reject the claim.
It’s important to note that a challenge does not guarantee a changed decision. The PIC’s internal review is final unless the claimant appeals to the NSW Civil and Administrative Tribunal (NCAT) within 28 days.
Time limits and procedural steps
CTP claims must be submitted within 6 months of the accident, though extensions may apply for valid reasons. For disputes over aggravation, claimants should:
- Submit a formal dispute request to the PIC within 28 days of the initial decision.
- Provide additional evidence if new information emerges.
- Seek legal advice if the PIC’s decision is contested.
When to seek independent advice
Disputes over pre-existing injuries can be complex. Claimants should consult a solicitor if:
- The PIC denies the claim despite medical evidence.
- The claimant needs help navigating the internal review process.
- There are disputes over the extent of aggravation or causation.
Independent legal advice ensures claimants understand their options and meet all procedural deadlines.
Next steps
CTP claims involving pre-existing injuries require careful documentation and evidence. The PIC’s expectations are clear but strict, particularly around proving aggravation. If you’re unsure how to proceed, complete the quick, no obligation enquiry form to request contact about your circumstances.