Understanding Wrist Fractures in NSW CTP Claims
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).
A wrist fracture sustained during a motor accident in Greater Sydney may form the basis of a claim under the NSW Compulsory Third Party (CTP) insurance scheme. The Personal Injury Claimant (PIC), the injured person, expects that their claim will be assessed fairly under the Motor Accident Injuries Act 2017 (MAIA), which governs all CTP claims in NSW. The PIC expects that medical evidence will be reviewed objectively, that treatment and care benefits will be provided as needed, and that any dispute over the injury’s severity or impact will be resolved through the formal processes set out by the State Insurance Regulatory Authority (SIRA). Disputes often arise when the insurer questions the nature of the fracture, the need for ongoing treatment, or whether the injury meets the threshold for damages. The PIC expects transparency, consistency, and adherence to the Motor Accident Guidelines in these assessments.
What the PIC Expects in Disputes: Key Legal Principles
Under the MAIA, the PIC expects that a wrist fracture will be treated as a valid injury if it is medically confirmed and related to the motor accident. The PIC expects that the insurer will not dispute the injury solely because it is not a high-impact trauma, as wrist fractures commonly occur from bracing during sudden impact. The PIC also expects that the insurer will not automatically reject a claim based on the absence of visible external trauma. The Motor Accident Guidelines state that fractures may be diagnosed through imaging such as X-rays or MRI, and that a diagnosis made by a qualified medical practitioner is sufficient for claim assessment.
The PIC expects that disputes over treatment will be resolved by reference to clinical standards. If a claimant requires surgery, rehabilitation, or ongoing physiotherapy, the PIC expects that these interventions will be approved if supported by a treating medical practitioner. The PIC also expects that any dispute over the need for treatment will be referred to a medical review under the SIRA dispute resolution pathway. The PIC does not expect that a claim will be denied simply because the injury is not life-threatening or because it occurred in a low-speed collision.
Evidence That Matters in Wrist Fracture Disputes
To meet the PIC’s expectations, claimants must provide clear and contemporaneous evidence. The most critical evidence includes:
- A formal diagnosis of a wrist fracture from a medical practitioner, supported by imaging such as an X-ray or MRI.
- Medical records showing the date of injury, treatment received, and ongoing management.
- A contemporaneous account of the accident, including how the injury occurred (e.g., bracing during impact, impact with the vehicle’s interior).
- Photographs of the injury site, if visible, and any vehicle damage that supports the impact description.
- Witness statements, if available, confirming the nature of the impact and the claimant’s reaction at the time.
- Records of any lost income, if the injury affects the ability to work.
The PIC expects that insurers will not dismiss a claim based on a lack of immediate symptoms. Delayed onset of pain or swelling is common with wrist fractures, particularly if the injury is to the scaphoid bone, which may not be visible on initial X-rays. The PIC expects that a follow-up scan or specialist review will be accepted as valid evidence if the initial imaging was inconclusive.
Navigating Disputes: The PIC’s Pathway to Resolution
If a dispute arises over the wrist fracture, for example, the insurer denies treatment, challenges the diagnosis, or refuses to pay weekly income benefits, the PIC expects to follow a structured process. The first step is to request a formal review from the insurer. If the dispute remains unresolved, the PIC may apply to the Personal Injury Commission (PIC) for a medical dispute determination. This process allows a qualified medical practitioner to assess whether the injury meets the criteria for treatment and care benefits, or whether the claimant has a whole person impairment (WPI) that may qualify for damages.
The PIC expects that a medical dispute will be heard within a reasonable timeframe, typically within 12 weeks of submission, and that the decision will be based on the Motor Accident Guidelines and current clinical standards. The PIC also expects that any decision can be appealed to the NSW Civil and Administrative Tribunal (NCAT) if the outcome is not accepted. The PIC does not expect that a challenge will automatically change the insurer’s position, but that the process will provide a fair and independent assessment.
Time Limits and Practical Steps
The PIC expects that all claims must be made within the time limits set by the MAIA. A claim for treatment and care benefits must be made within 12 months of the accident. A claim for damages must be made within three years of the accident, unless the injury is a threshold injury, in which case the time limit for damages may be extended under transitional provisions. The PIC expects that delays in reporting the injury will not automatically disqualify a claim, but that prompt reporting is essential to preserve evidence.
The PIC expects that claimants will not alter, conceal, or fabricate evidence. The PIC also expects that claimants will not delay treatment to strengthen a claim. The insurer is entitled to review the claim for consistency, and any discrepancy may result in a dispute. The PIC expects that the insurer will not use a claimant’s prior medical history to deny a claim unless that history is directly relevant to the current injury.
When to Seek Independent Advice
The PIC expects that not all disputes can be resolved through negotiation. If the insurer refuses to provide benefits, challenges the diagnosis, or disputes the need for rehabilitation, the PIC expects that independent legal or medical advice should be sought. The PIC does not expect that a claim will be successful simply because it is disputed, but that the process will be fair and evidence-based.
A realistic example: A 34-year-old cyclist in Sydney’s Inner West sustained a scaphoid fracture after colliding with a car at a roundabout. The injury was not visible initially, but an MRI performed three days later confirmed the fracture. The insurer initially denied treatment benefits, citing a lack of immediate symptoms. The claimant submitted medical records, imaging, and a treating surgeon’s report. The dispute was referred to the Personal Injury Commission, which upheld the claim based on the medical evidence and the Motor Accident Guidelines. The PIC expected this outcome because the evidence met the statutory standards.
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