Dispute Resolution Options for Traumatic Brain Injury Claims in NSW
If you have suffered a traumatic brain injury in a motor accident in New South Wales, and your claim for compensation has been disputed by an insurer or the insurer has refused to pay a benefit you believe you are entitled to, several formal dispute resolution options are available under the Motor Accident Injuries Act 2017 (MAIA). These options are designed to resolve disagreements about entitlements, the amount of benefits, or the assessment of injury impact, including for complex injuries like traumatic brain injury. The process is managed by the State Insurance Regulatory Authority (SIRA), which oversees the CTP scheme in NSW. Disputes may arise over treatment and care benefits, weekly income payments, or the assessment of whole person impairment (WPI) for damages. The resolution pathway includes internal review, formal dispute resolution through SIRA, and, where necessary, referral to the Personal Injury Commission (PIC) for medical dispute resolution.
How SIRA Manages Disputes in Traumatic Brain Injury Cases
SIRA is the statutory authority responsible for administering the CTP scheme in NSW and handling disputes. When a claim for a traumatic brain injury is disputed, the insurer must provide a written reasons statement outlining why they have refused or limited a benefit. This statement must be issued within a reasonable time after the decision is made. If you disagree with the insurer’s decision, you may request an internal review. This internal review is conducted by the insurer and must be completed within 28 days of your request. The insurer must provide a written response and explain any changes to their original decision.
If the internal review does not resolve the dispute, or if you are not satisfied with the outcome, you may apply to SIRA for formal dispute resolution. SIRA will assess the claim and may require further information, including medical evidence, to determine whether the insurer’s decision was correct. For traumatic brain injuries, SIRA will consider the nature and severity of the injury, the impact on your daily life and capacity to work, and whether the injury meets the threshold for damages under the MAIA. SIRA may also refer the matter to the Personal Injury Commission (PIC) if there is a dispute about the medical assessment of impairment, particularly where a medical report has been issued by a qualified medical assessor.
Practical Steps and Evidence That Matter in Dispute Resolution
To resolve a dispute over a traumatic brain injury claim, you must gather and preserve evidence that supports your claim. This includes:
- Medical records from your treating medical practitioners, including neurologists, neuropsychologists, and rehabilitation specialists.
- Reports from independent medical assessors, particularly those assessing whole person impairment (WPI) and functional capacity.
- Documentation of any cognitive, emotional, or behavioural changes resulting from the injury, such as memory loss, concentration difficulties, or mood disorders.
- Evidence of impact on your ability to work, including a letter from your employer or a vocational assessment.
- Records of treatment and care, including therapy sessions, medication, and assistive devices.
- Photographs of the accident scene, vehicle damage, and any visible injuries at the time of the accident.
- Witness statements, if available, describing your condition immediately after the accident.
A hypothetical example: A 38-year-old office worker in Sydney sustained a traumatic brain injury in a rear-end collision in the Eastern Suburbs. The insurer initially refused a weekly income payment on the grounds that the injury was not severe enough to affect capacity to work. After providing a neuropsychological report showing cognitive deficits and a vocational assessment confirming reduced work capacity, the claimant requested an internal review. The insurer upheld the original decision. The claimant then applied to SIRA for dispute resolution, which referred the medical assessment to the PIC. Following a review, the PIC concluded that the injury caused a 15% WPI and recommended a weekly income payment. SIRA accepted this and directed the insurer to pay the benefit.
Time Limits, Dispute Timelines and When to Seek Advice
There are time limits that apply to dispute resolution under the MAIA. You must request an internal review within 28 days of receiving the insurer’s written reasons. If you do not request an internal review within this timeframe, you may still apply to SIRA for dispute resolution, but you must do so within 12 months of receiving the insurer’s decision. The SIRA dispute resolution process must be completed within 90 days of the application, unless an extension is granted. If the matter proceeds to the Personal Injury Commission, the medical dispute resolution process must be completed within 60 days of the referral.
It is important to understand that a dispute resolution process does not guarantee a change in the insurer’s decision. The outcome depends on the strength of the evidence and whether the insurer’s original decision was supported by law and medical evidence. If the dispute is not resolved through SIRA or the PIC, you may have the option to apply to the NSW Civil and Administrative Tribunal (NCAT) for a determination, but this is only available in limited circumstances and only after exhausting the SIRA and PIC pathways.
If you have a traumatic brain injury and are facing a dispute over your CTP claim, it is essential to seek independent legal advice early. The complexity of brain injury assessments, the need for specialist medical evidence, and the procedural requirements of the CTP scheme mean that delays or errors in submission can affect your entitlement. You should not delay in gathering evidence, notifying the insurer of your disagreement, and initiating the review process.
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