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).
In New South Wales, insurers assess claims for shoulder injuries under the Compulsory Third Party (CTP) scheme by evaluating medical evidence, injury severity, and the circumstances of the accident. This article explains how insurers evaluate claims for shoulder injuries, with a focus on regional NSW, and outlines practical steps to support your claim.
How NSW CTP Insurers Assess Shoulder Injury Claims
Under the Motor Accident Injuries Act 2017, insurers must assess claims based on the nature of the injury and its impact on the injured person. For shoulder injuries, insurers typically consider:
- Medical documentation: Detailed records from medical practitioners confirming the injury, such as MRI scans, X-rays, or clinical notes. For example, a rotator cuff tear requiring surgery would be evaluated based on specialist reports.
- Injury severity: Whether the injury meets the 'threshold injury' definition under the Motor Accident Guidelines. This includes assessing neurological signs, such as weakness or numbness, and functional limitations.
- Impact on daily life: Evidence of reduced mobility, pain, or inability to work. Insurers may request a report from a physiotherapist or occupational therapist.
- Accident circumstances: How the injury occurred, including vehicle speed, collision type, and witness statements. In regional areas, limited access to specialists or delayed medical attention may influence the assessment.
Regional NSW Considerations
In regional NSW, claims may face additional challenges compared to metropolitan areas. For instance:
- Access to medical specialists: Rural areas may have fewer orthopaedic surgeons or physiotherapists, potentially delaying diagnosis or treatment. Insurers may scrutinise delays in seeking care.
- Processing times: Claims in regional areas may take longer to process due to logistical challenges, such as longer travel times for medical appointments or limited local CTP insurer resources.
- Witness availability: In smaller communities, witnesses may be less likely to report the accident, affecting the insurer's ability to verify details.
Practical Steps to Support Your Claim
To strengthen your claim, gather the following evidence:
- Medical records: Ensure your treating practitioner documents the injury's impact on your daily activities. For example, a doctor's note stating you cannot lift objects above shoulder height.
- Accident report: Obtain a police report or statement from the scene, including details of the collision and any visible damage.
- Witness statements: If possible, collect statements from witnesses who observed the accident, especially regarding vehicle speeds or road conditions.
- Photographs: Document the accident scene, vehicle damage, and any visible injuries. For example, a photo of a bruised shoulder or a dislocated joint.
- Income records: If the injury affects your ability to work, provide payslips or employment records to support claims for lost wages.
Time Limits and Dispute Resolution
Under the CTP scheme, you have 6 years from the date of the accident to make a claim. However, insurers may initiate a review of your claim if they believe the injury does not meet the threshold or if there are delays in treatment. If your claim is disputed, you can:
- Request a review: Submit additional evidence to the insurer to challenge their assessment.
- Seek independent medical opinion: Obtain a second opinion from a specialist to support your case.
- Contact SIRA: The State Insurance Regulatory Authority (SIRA) oversees CTP claims and can mediate disputes. Visit SIRA's claims page for guidance.
When to Seek Legal Advice
If your claim is rejected or you face disputes over the injury's severity, consider consulting a solicitor. Legal professionals can help:
- Navigate the claims process and identify gaps in your evidence.
- Challenge an insurer's decision to exclude your injury from coverage.
- Negotiate a fair settlement based on your medical and financial losses.
Example Scenario
Consider a driver involved in a collision where their shoulder was injured. The driver sought treatment at a regional hospital but faced delays in accessing a specialist. The insurer initially denied the claim, arguing the injury did not meet the threshold. However, the driver provided MRI scans showing a rotator cuff tear and a physiotherapist's report detailing limited mobility. This evidence persuaded the insurer to approve the claim.
Next Steps
CTP claims depend on the specific facts of your case, including the injury's severity, medical evidence, and the accident's circumstances. To request contact about your circumstances, complete the quick, no obligation enquiry form.