NSW CTP medical services

This is where the confusion starts. SIRA's guidanceis that where an injury results from a work-related motor crash, a workers' compensation claim also has to be made against the employer's workers' compensation insurer.

The two schemes do not both pay for the same injury. Under section 3.35 of the Motor Accident Injuries Act 2017, a person is not entitled to CTP statutory benefits if compensation under the Workers Compensation Act 1987 is payable for that injury. The same section lets a CTP insurer require the injured person to lodge a workers' compensation claim where it has reasonable grounds to think one is payable, and obliges anyone running both claims to tell both insurers.

So workers' compensation is usually the first route for a worker hurt driving for work, while the CTP claim still matters — for damages against an at-fault driver, and for treatment later. Section 6.13(4)allows a CTP claim for treatment and care within three months after workers' compensation medical compensation ceases to be payable.

Whether a crash is work-related is not always obvious. A delivery run in work time generally is; the commute usually is not. Section 10(3A) of the Workers Compensation Act 1987 covers a journey to or from a worker's home only where there is a real and substantial connection between the employment and the accident. Insurers resolve that, not treating doctors — but they resolve it on the clinical record.

Your reporting obligation does not wait for the answer. Section 44(2) of the Workplace Injury Management and Workers Compensation Act 1998 requires an employer to notify their insurer or the Nominal Insurer within 48 hours of becoming aware that a worker has been injured.

The certificate of fitness is the CTP scheme's medical certificate. SIRA describes it as setting out the nature of the injuries, fitness for work and treatment required, and says the insurer uses it to assess the person's ability to work regardless of their employment status. The first certificate must be completed by the person's registered medical practitioner during a consultation; subsequent certificates may be issued by a treating physiotherapist or psychologist. It cannot cover more than 28 days without specific reasons, and weekly benefits may be suspended if the insurer does not receive a valid certificate.

A certificate of capacity does the equivalent job in workers' compensation, and SIRA publishes a single combined form for a patient injured at work or in a motor vehicle accident, with guidance that an unclear diagnosis be recorded as provisional and updated once confirmed, and that capacity be certified as capacity for all pre-injury work, some type of work, or no current capacity.

The differences that matter to an employer are routing and audience. In workers' compensation the certificate may go to the employer, and the doctor may take on the nominated treating doctor role. In CTP the injured person submits it to the insurer. One crash producing both claims means two certificate trails — which is precisely where documentation drifts.

“Threshold injury” is defined in section 1.6 of the Act as a soft tissue injury, or a psychological or psychiatric injury that is not a recognised psychiatric illness — soft tissue meaning tissue that connects, supports or surrounds other structures or organs, but not nerves, and not a complete or partial rupture of tendons, ligaments, menisci or cartilage.

SIRA's explanation of threshold injury gives the clinical edges: fractures, nerve injuries, ruptures and radiculopathy are examples of non-threshold physical injuries, while adjustment disorder and acute stress disorder count as threshold psychological injuries even though depression and PTSD do not.

The consequence is financial. Where the only injuries are threshold injuries, weekly payments cease 52 weeks after the accident under section 3.11, treatment and care expenses cease at the same point under section 3.28, and damages are not available at all.

Classification is the insurer's call, not the doctor's. SIRA states that the treating doctor or health professional diagnoses the injury, and the insurer then decides whether it is a threshold injury taking that assessment into account, notifying the person within nine months of the claim being lodged. Each injury is classified separately: if at least one is not a threshold injury, the claim is not a threshold injury claim. That is why a precise diagnosis, revised when imaging or nerve studies confirm it, carries so much weight. Our job is to record what the examination and investigations support.

The CTP scheme funds return-to-work support much as the workers' compensation scheme does, which employers rarely realise. SIRA administers four programs under section 3.41 of the Act — Recover at Work Assist, the JobCover Placement Program, JobCover6 and Transition to Work.

Recover at Work Assist is the one aimed at the pre-accident employer. It provides up to $400 per week for up to 12 weeks where an eligible employer offers suitable work through a graded recover at work plan, with the injured person certified as having current fitness for work on a certificate of fitness and receiving or entitled to weekly payments. Applications go to SIRA through the CTP insurer managing the claim. The JobCover Placement Program works the other way, offering incentives of up to $27,400 over up to 12 months to an employer other than the pre-accident employer who takes on someone unable to return to their previous job.

Our contribution to either is the clinical half — the certificate of fitness and a graded plan built around the real demands of the role. Eligibility and approval sit with SIRA and the insurer.