What the PIC Expects in Spinal Injury Disputes
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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 spinal injury in a motor accident in NSW, the Personal Injury Commission (PIC) determines your eligibility for compensation. Spinal injuries are complex, and disputes often arise over whether the injury meets the threshold for benefits or if the claimant's needs are fully covered. The PIC evaluates claims based on medical evidence, the nature of the injury, and the impact on daily life. Understanding what the PIC expects in disputes is critical to securing fair treatment.
NSW CTP Rules for Spinal Injuries
Under the Motor Accident Injuries Act 2017, spinal injuries are assessed using the Motor Accident Guidelines. A spinal injury may qualify as a 'threshold injury' if it involves a spinal nerve-root injury producing neurological signs, such as weakness or numbness, even if radiculopathy (nerve root irritation) is not present. The PIC considers whether the injury results in long-term or permanent impairment, and whether it affects the claimant's ability to work or perform daily activities.
For claims involving spinal injuries, the PIC may dispute the severity of the injury or the need for ongoing support. For example, if a claimant's injury is below the threshold, the PIC may limit benefits after 52 weeks. If the injury is above the threshold, the PIC may challenge the claimant's assertion of long-term impairment.
Evidence Critical to Spinal Injury Claims
To support a spinal injury claim, you must provide:
- Medical records showing the injury's cause, diagnosis, and treatment.
- Expert opinions from medical practitioners confirming the injury's severity.
- Evidence of daily impact, such as difficulty walking, loss of mobility, or chronic pain.
- Documentation of treatment costs, including physiotherapy, specialist consultations, and equipment.
The PIC may dispute claims if evidence is incomplete or if the injury does not meet the threshold. For instance, a claimant who claims long-term disability but has no documented impairment may struggle to prove their case.
Common Dispute Points in Spinal Injury Claims
- Threshold injury classification: The PIC may dispute whether the injury qualifies as a threshold injury, requiring clinical signs like neurological deficits.
- Contributory fault: If the claimant contributed to the accident, the PIC may reduce benefits.
- Long-term impairment: The PIC may challenge claims of permanent disability, especially if the injury is not severe enough to meet impairment thresholds.
- 52-week limit: If the injury is below the threshold, the PIC may argue that benefits should stop after 52 weeks.
How the PIC Resolves Disputes
If the PIC disputes a claim, you may request a review through the internal review process. This involves submitting new evidence or a revised assessment of the injury. The PIC may also refer the claim to an independent medical expert for further evaluation. However, a challenge does not guarantee a changed decision. The PIC's final determination is based on the evidence and the Motor Accident Guidelines.
Practical Steps for Claimants
- Seek immediate medical attention to document the injury.
- Keep all medical records and correspondence with healthcare providers.
- Notify your insurer as soon as possible to start the claims process.
- Consult a solicitor if the PIC disputes your claim, as legal advice can help navigate the review process.
When to Seek Legal Advice
Disputes over spinal injuries can be complex, especially if the PIC challenges the severity of the injury or the need for ongoing support. A solicitor can help you understand your options, prepare for a review, and ensure your claim is properly presented. Legal advice is particularly valuable if the PIC's decision is based on incomplete or disputed evidence.
Next Steps
CTP claims involving spinal injuries depend on the specific facts of the accident, the nature of the injury, and the evidence provided. Time limits and procedural requirements may apply, so it's important to act promptly. To request contact about your circumstances, complete the quick, no obligation enquiry form.