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're disputing a treatment provider's decision about your ability to return to daily activities under NSW CTP laws, understanding SIRA's assessment process is critical. This article explains how disputes over daily activity restoration are resolved, what evidence is needed, and practical steps for regional claimants.
How SIRA Assesses Treatment Provider Disputes
SIRA evaluates disputes by considering medical evidence, treatment plans, and your ability to perform daily activities. Under the Motor Accident Injuries Act 2017, treatment providers must approve care that aligns with your injury's severity and recovery progress. If a provider disputes your capacity to return to activities, SIRA will review medical records, rehabilitation reports, and any independent assessments to determine if your treatment plan is reasonable.
Key factors include:
- Whether your injuries meet the 'threshold injury' criteria under the Motor Accident Guidelines
- Evidence of your ability to perform daily tasks like cooking, shopping, or personal care
- Alignment of treatment with your recovery stage
Evidence Required for Daily Activity Claims
To support your case, gather:
- Detailed medical records showing your injury's impact on daily activities
- Rehabilitation reports outlining your progress and limitations
- Witness statements from family or carers about your daily challenges
- Photos or videos of your home environment if mobility is an issue
- Any correspondence with treatment providers about disputed aspects
In regional NSW, access to specialists may affect evidence collection. SIRA encourages claimants to seek independent assessments if treatment providers refuse to accommodate your needs.
Practical Steps for Regional Claimants
- Document daily limitations: Keep a journal of activities you can't perform and how they affect your life.
- Request independent review: If a provider disputes your treatment plan, ask SIRA to arrange an independent medical assessment.
- Submit evidence promptly: SIRA requires all documentation within 28 days of receiving a dispute notice.
- Seek clarification: If unsure about medical terminology, ask your treating doctor to explain how your injuries affect daily tasks.
Time Limits and Dispute Resolution
You have 52 weeks from the accident date to claim weekly benefits for threshold injuries. After this period, SIRA may limit benefits unless you can prove ongoing impairment. If a treatment provider disputes your recovery timeline, you can:
- Request a review of the provider's decision
- Appeal to the Personal Injury Commission (PIC) for a medical dispute resolution
- Seek independent expert opinion to challenge the provider's assessment
Note: SIRA's internal review process typically takes 6-8 weeks. If the dispute involves complex medical issues, the PIC may refer the case to a medical expert for further evaluation.
When to Seek Legal Advice
If a treatment provider refuses to approve necessary care, or if you're unsure how to challenge a decision, contact a solicitor specialising in CTP claims. Legal advice can help you:
- Navigate SIRA's complex assessment criteria
- Challenge unreasonable treatment refusals
- Ensure your daily activity limitations are properly documented
Example Scenario
Consider a claimant in regional NSW who developed chronic back pain after a car accident. Their treatment provider refuses to approve physiotherapy, arguing they've 'returned to normal activities.' The claimant submits medical evidence showing they can't lift groceries or walk long distances. SIRA reviews the evidence and determines the provider's decision is unreasonable, leading to approved treatment.
Next Steps
CTP disputes over daily activity restoration depend on medical evidence, treatment alignment, and timely action. If you're facing a treatment provider disagreement, act quickly to gather documentation and seek clarification from SIRA. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.