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).
Spinal injuries in NSW motor accident claims are governed by the Motor Accident Injuries Act 2017 and SIRA guidelines. This article answers key questions injured people ask about eligibility, assessment, treatment coverage, and dispute resolution. Understanding the legal framework and practical steps is critical for those seeking compensation.
What spinal injuries qualify for NSW CTP claims?
Under the Motor Accident Injuries Act 2017, spinal injuries must meet the 'threshold injury' definition in the Motor Accident Guidelines. This includes injuries like herniated discs, spinal stenosis, or fractures causing neurological signs. However, not all spinal injuries qualify. For example, a minor sprain without neurological impact typically does not meet the threshold. SIRA's guidelines specify that a spinal nerve-root injury producing neurological signs (other than radiculopathy) may still count as a threshold injury. Radiculopathy requires specific clinical signs like radicular pain or sensory loss. Importantly, injuries below this threshold are not covered under CTP.
How do insurers assess spinal injury claims?
Insurers use the Motor Accident Guidelines to evaluate claims. They require medical evidence, such as imaging reports and clinical notes, to confirm the injury meets the threshold. For example, a claimant with a herniated disc must show neurological signs like weakness or numbness. Insurers also consider the injury's impact on daily life, including pain levels and mobility. If the injury is below the threshold, insurers may deny the claim, even if the injury is severe.
What treatment costs are covered under CTP for spinal injuries?
CTP covers treatment and care benefits for threshold injuries. This includes physiotherapy, specialist consultations, and medical equipment like braces. Weekly income payments may also apply if the injury prevents work. However, if the injury is below the threshold, these benefits are not available. SIRA's 'What you can claim' page outlines eligible treatment costs, but it's essential to submit all medical records to support the claim.
What to do if a spinal injury claim is denied?
If your claim is denied, contact SIRA immediately to challenge the decision. You may also seek legal advice to review the assessment. Insurers must provide a written explanation for the denial, including the reason the injury does not meet the threshold. If the denial is based on incomplete evidence, you can submit additional medical records. Note that time limits apply: claims must be submitted within 52 weeks of the accident, or within 5 years if the injury was not immediately apparent.
Practical steps and evidence that usually matter
To support a spinal injury claim, gather: medical records detailing the injury and its impact, accident reports, witness statements, and photographs of the scene. Income records are also important to demonstrate lost earnings. If the injury requires long-term care, provide evidence of ongoing treatment needs. SIRA may request a medical assessment to verify the injury's severity.
Time limits, disputes and when to seek advice
Claims must be submitted within 52 weeks of the accident, or within 5 years if the injury was not immediately apparent. If the injury is below the threshold, you may still have options, such as pursuing a common law damages claim. However, CTP benefits are limited to threshold injuries. Seek legal advice if your claim is denied, especially if you believe the assessment is incorrect. A solicitor can help challenge the decision or explore alternative compensation pathways.
Real-world example: A spinal injury claim in action
Consider a driver who suffered a herniated disc after a collision. Medical records show neurological signs like leg weakness, meeting the threshold injury definition. The insurer approves treatment benefits, including physiotherapy and a brace. However, if the injury was a minor strain without neurological impact, the claim would be denied. This example highlights the importance of accurate medical documentation in determining eligibility.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.