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 sustained in a motor accident in NSW are assessed under the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. Insurers in Ballina, like all CTP insurers operating under the SIRA scheme, must determine entitlement to benefits based on medical evidence, injury severity, and statutory thresholds. Decisions are not made arbitrarily but follow SIRA’s published guidelines, including the Motor Accident Guidelines, which define what constitutes a compensable injury and how impairment is assessed. The process involves evaluating whether the injury is a threshold injury, whether it results in permanent impairment, and whether the claimant qualifies for damages. Insurers must also consider the nature of the injury, the impact on daily life and capacity to work, and whether the injury is attributable to the accident. These assessments are critical in determining the level of treatment and care benefits, weekly income payments, and any claim for damages.
The Motor Accident Injuries Act 2017 establishes that a spinal injury may be compensable if it results in a permanent impairment, even if it does not meet the threshold injury definition. However, if the injury is classified as a threshold injury, such as a soft-tissue injury with neurological signs, then the claimant may only be entitled to statutory benefits for up to 52 weeks, unless they meet the criteria for damages. The Act provides that where a person’s only injuries are threshold injuries, treatment and care benefits and weekly income payments are generally limited after 52 weeks. This rule applies regardless of the location of the accident, including in Ballina, and is not subject to discretion by the insurer.
Insurers assess spinal injury claims using medical evidence that must be independently verified. This includes reports from medical practitioners, imaging results (such as MRI or CT scans), and assessments of whole person impairment (WPI) conducted by qualified assessors. The Motor Accident Guidelines set out the clinical criteria for diagnosing spinal nerve-root injuries and define when neurological signs other than radiculopathy may still qualify as a soft-tissue injury under the Act. For example, if a claimant has a spinal nerve-root injury with objective signs such as muscle weakness or sensory changes, but not the specific signs required for radiculopathy, it may still be considered a threshold injury. Insurers must accept these assessments unless there is a reasonable basis to dispute them, and they must provide written reasons for any decision to deny or limit benefits.
Claimants in Ballina should preserve all evidence related to the accident and injury. This includes medical records from the time of the accident through to current treatment, photographs of the accident scene, witness contact details, and any correspondence with the insurer. The insurer is required to notify the claimant in writing of any decision, including the reasons for denying a claim or limiting benefits. If a claimant disagrees with an insurer’s decision, they may request a review under the Motor Accident Injuries Regulation 2017. The claimant may also apply to the NSW Civil and Administrative Tribunal (NCAT) for a review of the decision if the insurer does not change its position. This process is available for disputes about entitlement to benefits, the level of benefits, or the assessment of impairment.
A claimant may also seek a second opinion from a medical practitioner approved under the Motor Accident Guidelines. This is particularly relevant for spinal injuries, where the nature and extent of the injury may be complex. The insurer is required to consider a second opinion and may not unreasonably reject it. If the second opinion differs from the insurer’s assessment, the claimant may use it to support a claim for damages, particularly if the injury results in a permanent impairment of 10% or more. The claimant must also ensure that all medical treatment is related to the accident and documented in a way that supports its connection to the injury.
A hypothetical example: A 42-year-old driver in Ballina was involved in a rear-end collision in August 2024. The driver developed chronic lower back pain and was diagnosed with a spinal nerve-root injury affecting the sciatic nerve. MRI scans showed nerve compression, and a qualified assessor determined a WPI of 12%. The insurer initially denied a claim for damages, arguing the injury was a threshold injury. The claimant obtained a second medical assessment confirming permanent impairment and submitted it with a formal request for a review. The insurer later accepted the claim, and the claimant received weekly income payments and damages for pain and suffering and loss of capacity to earn.
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