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 traumatic brain injury in a motor accident in NSW, understanding what the Personal Injury Claimant (PIC) expects during disputes is critical. The NSW Compulsory Third Party (CTP) scheme governs claims for injuries like yours, but disputes often arise over medical assessments, compensation levels, or claim timelines. This article explains what claimants should expect when challenging decisions under the Motor Accident Injuries Act 2017 (MAIA) and how to navigate SIRA’s guidelines effectively.
What the PIC Expects in Traumatic Brain Injury Disputes
The PIC, typically a medical assessor or SIRA representative, evaluates claims based on strict legal and medical criteria. For traumatic brain injuries, the PIC will expect:
- Medical evidence confirming the injury meets the threshold for CTP claims (e.g., neurological signs or imaging). SIRA’s guidelines state that injuries must result in "a significant loss of function" to qualify for compensation.
- Documentation of long-term effects, such as cognitive impairments, memory loss, or emotional symptoms, as these determine the severity rating.
- Compliance with the 52-week rule. If your injury is classified as a "threshold injury" (e.g., a minor concussion without lasting impairment), benefits may stop after 52 weeks unless there’s evidence of ongoing consequences.
How SIRA Handles Disputes Over Traumatic Brain Injuries
SIRA assesses claims using the Motor Accident Guidelines, which define what constitutes a "threshold injury" or a more severe "whole person impairment." If your claim is disputed:
- The PIC may request independent medical opinions to verify the injury’s severity.
- You may need to provide updated medical records showing ongoing symptoms or treatment.
- SIRA may refer the case to the Personal Injury Commission (PIC) for a formal review, which can take up to 12 months.
Legal Boundaries for Dispute Resolution
Disputes over traumatic brain injuries are subject to specific legal limits:
- No guaranteed outcome: A challenge does not automatically lead to a revised decision. The PIC must find "clear and convincing evidence" that the original assessment was incorrect.
- Time limits: You must lodge a dispute within 28 days of receiving a decision, or within 28 days of a new decision if the claim is reassessed.
- No right to legal representation: While you may seek advice, the PIC’s process is designed for claimants to navigate without a lawyer.
Practical Steps for Claimants
To strengthen your case during a dispute:
- Gather all medical records from your treating practitioners, including scans, therapy notes, and specialist reports.
- Document daily impacts of the injury, such as difficulty concentrating, memory lapses, or emotional distress.
- Request a copy of the PIC’s decision to understand the reasoning behind the disputed assessment.
- Seek independent opinions if your injury’s severity is contested, such as a neuropsychological assessment.
When to Seek Advice
Disputes over traumatic brain injuries can be complex. If you’re unsure whether your claim meets the threshold, or if you need help challenging a decision, contact a legal professional. While the CTP scheme is designed for claimants to manage on their own, navigating disputes often requires expert guidance to ensure your rights are protected.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.