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 you've suffered a shoulder injury in a car accident on the Central Coast, you may be wondering how the NSW Compulsory Third Party (CTP) scheme funds your treatment costs. The answer depends on the type of injury, when it occurred, and whether it meets the legal definition of a 'threshold injury' under the Motor Accident Injuries Act 2017. This article explains how the CTP scheme covers treatment expenses for shoulder injuries, what evidence matters, and when to seek legal advice.
How the NSW CTP Scheme Funds Shoulder Injuries
The CTP scheme covers treatment costs for injuries that meet the 'threshold injury' definition in the Motor Accident Guidelines. For shoulder injuries, this typically includes rotator cuff tears, dislocations, and fractures requiring medical intervention. Under the scheme, you may claim:
- Treatment and care benefits for physiotherapy, surgery, and specialist consultations
- Weekly income payments if the injury prevents you from working
- Statutory benefits for medical expenses, travel, and lost income
SIRA (State Insurance Regulatory Authority) administers these claims. If your injury meets the threshold, the CTP insurer must cover treatment costs, including those for shoulder injuries on the Central Coast. However, the scheme does not cover all medical expenses, only those directly related to the accident.
Key Considerations for Shoulder Injuries
- Threshold injury definition: A shoulder injury must produce neurological signs, such as weakness or numbness, to qualify as a threshold injury. For example, a rotator cuff tear that limits arm movement may qualify, while a minor sprain typically does not. SIRA’s guidelines specify that injuries must meet both clinical and functional criteria.
- Time limits: If your injury is a 'threshold injury', you may receive weekly benefits for up to 52 weeks. After that, the CTP insurer may stop payments unless you can prove the injury has caused long-term impairment. For non-threshold injuries, the scheme does not cover treatment costs.
- Evidence requirements: You must provide medical records confirming the injury, a diagnosis of a threshold injury, and evidence of treatment costs. Keep receipts for physiotherapy, scans, and specialist consultations. If your injury requires surgery, ensure your surgeon documents the connection to the accident.
Practical Steps for Central Coast Residents
If you’ve been in a car accident on the Central Coast and are experiencing shoulder pain, take these steps:
- Seek immediate medical attention to document the injury. A GP or physiotherapist can assess whether your shoulder injury meets the threshold definition.
- Preserve accident details: Gather police reports, witness statements, and photos of the damage. These help establish the accident’s circumstances and may influence your claim.
- Notify the CTP insurer as soon as possible. Delays can affect your ability to claim benefits, especially if your injury worsens over time.
When to Seek Legal Advice
While the CTP scheme covers many treatment costs, disputes can arise. For example, if your insurer disputes whether your shoulder injury qualifies as a threshold injury, you may need to:
- Request a review of your medical records by a specialist
- Challenge the insurer’s decision if you believe the injury meets the threshold
- Seek legal assistance if the insurer refuses to pay for necessary treatment
If your injury involves complex treatment, such as shoulder surgery or long-term physiotherapy, a solicitor can help ensure you receive full coverage under the CTP scheme.
Example: Rotator Cuff Tear on the Central Coast
Consider a hypothetical case: A driver on the Central Coast suffers a rotator cuff tear after a collision. A physiotherapist confirms the tear limits arm movement, meeting the threshold injury definition. Under the CTP scheme, the insurer must cover the cost of surgery, physiotherapy, and lost income during recovery. However, if the injury is later found to be a minor strain, the claim may be denied.
Next Steps
CTP claims depend on the date of the accident, the type of injury, and the evidence you provide. If you’re unsure whether your shoulder injury qualifies for funding, complete the quick, no obligation enquiry form to request contact about your circumstances. Every claim depends on its own facts.