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 CTP claims are assessed based on medical evidence and the Motor Accident Injuries Act 2017. Insurers evaluate whether the injury meets the 'threshold injury' definition under the Motor Accident Guidelines, which includes spinal nerve-root injuries with neurological signs. This article explains how insurers make decisions, factors influencing their assessments, and steps to challenge unfavorable outcomes in Armidale.
Legal Framework for Spinal Injury Claims
NSW CTP insurers rely on the Motor Accident Injuries Act 2017 and SIRA guidelines to determine eligibility. Spinal injuries must meet the 'threshold injury' criteria, which requires a spinal nerve-root injury producing neurological signs other than radiculopathy. Radiculopathy (nerve root irritation) must have specific clinical signs, such as pain radiating down a limb or muscle weakness, as outlined in the Motor Accident Guidelines.
Insurers also consider whether the injury results in a 'whole person impairment' (WPI) of 10% or more. For example, a herniated disc causing chronic pain and limited mobility might qualify, while a minor sprain without neurological signs would not. The 52-week statutory benefit limit applies if the only injuries are threshold injuries, meaning weekly payments and treatment benefits stop after 52 weeks.
Factors Insurers Consider
When assessing spinal claims, insurers examine:
- Medical records confirming the injury's nature and severity
- Imaging reports (e.g., MRI, X-rays) showing spinal damage
- Evidence of ongoing symptoms, such as pain, numbness, or mobility issues
- Rehabilitation records and treatment plans
- Income impact, if applicable
For example, a claimant with a spinal injury requiring long-term physiotherapy would need documentation showing the injury's effect on daily activities. Insurers may also review the accident report to determine if the injury was caused by a motor vehicle incident covered under CTP.
Practical Steps and Evidence
To support a spinal injury claim, gather:
- Detailed medical notes from a specialist
- Imaging reports confirming spinal damage
- A rehabilitation plan from a physiotherapist
- Proof of income loss, if applicable
- Witness statements or accident reports
In Armidale, claimants should contact SIRA directly to submit claims. If the insurer denies a claim, the claimant can request a review or escalate to the NSW Civil and Administrative Tribunal (NCAT) under section 122 of the Motor Accident Injuries Act 2017.
Disputes and When to Seek Advice
If an insurer rejects a claim, the claimant should:
- Request a written explanation of the decision
- Submit additional evidence, such as a second medical opinion
- Lodge a formal dispute with SIRA
- Seek legal advice if the claim is denied
In cases where the injury meets the threshold but the insurer disputes long-term support needs, claimants should consult a solicitor familiar with CTP disputes. For example, a claimant with a spinal injury requiring a wheelchair might need to prove that the injury significantly affects their quality of life to qualify for ongoing benefits.
Next Steps
CTP claims involving spinal injuries depend on accurate medical assessments and timely action. If you're in Armidale and need help understanding an insurer's decision, complete the quick, no obligation enquiry form to request contact about your circumstances.