How SIRA Handles Shoulder Injury Claims in NSW CTP
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).
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).
Shoulder injuries from motor vehicle accidents are commonly assessed under the Motor Accident Injuries Act 2017. The New South Wales State Insurance Regulatory Authority (SIRA) manages claims through the Compulsory Third Party (CTP) scheme. For shoulder injuries, SIRA evaluates whether the injury meets the 'threshold injury' definition in the Motor Accident Guidelines. This includes rotator cuff tears, dislocations, and fractures requiring medical intervention. If a claim is denied, injured parties can challenge the decision through internal review processes.
Dispute Resolution Options for Central Coast Claims
When a shoulder injury claim is disputed, injured individuals have several options. First, they can request an internal review with SIRA. This involves submitting new evidence, such as updated medical reports or expert opinions, to challenge the initial assessment. If the dispute persists, parties may escalate the matter to the Personal Injury Commission (PIC) for a formal review. The PIC can order an independent medical assessment to determine if the injury meets the threshold for statutory benefits.
Practical Steps for Challenging Shoulder Injury Claims
To dispute a denied claim, injured parties must act quickly. First, gather all medical records documenting the injury, including scans, specialist reports, and treatment history. Ensure the records clearly link the injury to the accident. Next, review the claim assessment to identify errors, such as misclassification of the injury or incorrect application of the threshold guidelines. SIRA requires evidence of 'neurological signs' for certain injuries, so medical documentation must meet these criteria. If the claimant believes the injury exceeds the threshold, they should request a detailed explanation of why it was denied.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident for certain benefits. However, disputes about the assessment of injuries are not subject to this deadline. That said, injured parties should not delay seeking advice. SIRA has strict guidelines for assessing injuries, and delays can reduce the chances of a successful challenge. Legal experts can help identify gaps in the claim, such as missing evidence or misinterpretation of medical records. It is also important to note that SIRA's internal review process typically takes 28 days, and further escalation to the PIC may take several months.
Example of a Dispute Scenario
Consider a case where a cyclist sustains a shoulder dislocation after a car collision. The claimant submits medical records showing the injury, but SIRA denies the claim, stating it does not meet the threshold. The claimant can challenge this by providing additional evidence, such as a specialist's opinion confirming the injury's severity. If SIRA upholds the denial, the claimant may request a medical review through the PIC. This process allows for an independent assessment of whether the injury qualifies for statutory benefits.
Next Steps for Injured Claimants
Disputing a CTP claim for a shoulder injury requires careful documentation and timely action. Injured individuals should consult SIRA's guidelines to understand the assessment criteria and ensure their claim meets all requirements. If a dispute arises, seeking advice from a legal professional familiar with CTP claims can help navigate the process. Every claim depends on its own facts, and the outcome will depend on the evidence and applicable law. To request contact about your circumstances, complete the quick, no obligation enquiry form.