Not every win is a number.

Our client sustained a wrist injury in a workplace incident and needed surgery. The insurer declined to fund it, on the basis that the wrist injury was not work related.

A dispute about causation and a dispute about treatment are often the same dispute wearing different clothes. If the insurer does not accept that the injury came from work, it will not pay for anything that treats it, and the worker is left waiting with a condition that in many cases gets harder to fix the longer it goes untreated.

We arranged for our client to be examined by an independent medical examiner, who supported his account of how the injury had come about and its connection to his work. We then brought the matter before the Personal Injury Commission. The dispute was resolved through conciliation, with the insurer agreeing to fund the surgery.

Our client lodged a workers compensation claim which the insurer accepted. The insurer then calculated his pre injury average weekly earnings, known as PIAWE, at approximately $735 per week.

PIAWE matters a great deal, because weekly payments of compensation are calculated as a percentage of that figure. An error at this stage carries through every payment a worker receives, so a modest looking miscalculation can cost thousands of dollars over the life of a claim.

The starting point under Schedule 3 of the Workers Compensation Act 1987 is the 52 weeks of earnings immediately before the injury. That period can be adjusted where there has been a change of an ongoing nature to the worker’s employment arrangement that made a financially material difference to what he was earning. We reviewed our client’s earnings history and formed the view that exactly such a change had occurred, and that the insurer had calculated his PIAWE across a period that no longer reflected what he was actually earning when he was injured.

We put those submissions to the insurer and, when the dispute was not resolved, brought the matter before the Personal Injury Commission. The insurer ultimately agreed that its original calculation was incorrect. The matter resolved on the basis that our client’s PIAWE was approximately $1,100 per week, an increase of roughly 50 per cent on the figure the insurer had first applied.

The correction was applied to the whole of the claim, not just to payments going forward. The insurer was required to back pay the shortfall that had accumulated while the lower figure was in place, and to continue paying our client’s weekly benefits at the corrected rate.

Our client sustained multiple injuries in a workplace incident. The insurer accepted the claim and paid weekly benefits and medical treatment while he recovered.

The insurer then arranged for him to be examined by an independent medical examiner. That doctor formed the opinion that our client’s injuries had completely resolved and that he was fit to return to work. Relying on that opinion, the insurer stopped his weekly payments and ceased funding his medical treatment at the same time.

This is a difficult position for any injured worker. Income support and treatment tend to disappear together, and the loss of treatment often makes the underlying injury worse just as the money runs out. An insurer’s examiner sees a worker once, usually for a short appointment, and that snapshot can sit very awkwardly against what the treating doctors have observed over months.

We disputed the decision and brought the matter before the Personal Injury Commission. We also arranged for our client to be examined by our own independent medical examiners, whose reports supported his position on both the extent of his ongoing injuries and his capacity for work.

The dispute resolved by agreement. The insurer agreed to back pay about a year of weekly payments our client had gone without, to continue paying his weekly benefits at the agreed rate, and to resume funding his medical treatment.

Threshold injury disputes are among the most common we deal with in motor accident claims, and they are one of the areas where a challenge is most often worth making.

Under the Motor Accident Injuries Act 2017, an injury is a threshold injury if it is a soft tissue injury, or a psychological or psychiatric injury that is not a recognised psychiatric illness. When an insurer makes that determination, treatment and income support end after 52 weeks and section 4.4 of the Act shuts out any claim for damages. It is a decision with far reaching consequences, and it is made by the insurer in the first instance.

That decision can be disputed. We have acted for a considerable number of clients in matters where a threshold injury determination did not survive scrutiny. In some, the insurer reconsidered its position once we had assembled and put forward the medical evidence, and conceded that the injuries fell outside the threshold definition. In others, the dispute was determined by a medical assessor at the Personal Injury Commission following an application we lodged. There have been enough of these matters that it is not practical to set them all out.

One example gives a sense of how these disputes unfold. Our client’s vehicle was struck by another car whose driver had lost control. He sustained multiple physical injuries and psychological injuries, and yet the insurer maintained that everything he had suffered was a threshold injury. We lodged an application with the Commission on his behalf. The assessor determined that neither his physical injuries nor his psychological injury were threshold injuries. His entitlement to treatment and care continued beyond the 52 week mark, and the pathway to a claim for damages was opened to him.

Our client was a pedestrian who was seriously injured when she was struck by a car while crossing the road away from a marked pedestrian crossing. Her son lodged a claim for nervous shock arising from the same accident.

The insurer’s initial position was that our client was 80% responsible for the accident. A finding at that level does two things to a claim. It reduces any award of damages by the same proportion, so that a claim worth a substantial sum on its face is cut to a fraction of it. It also puts an injured person past the 61% mark at which the Motor Accident Injuries Act 2017 treats them as mostly at fault, which brings statutory benefits, including funded treatment, to an end after 52 weeks.

The consequences reached further than our client’s own claim. A nervous shock claim is derivative, which means the deduction for the injured person’s contributory negligence flows through to it. At 80%, her son’s claim faced the same reduction as hers, so both members of the family stood to lose the greater part of what their claims were worth.

The matter was resolved at an informal settlement conference, with the insurer agreeing that our client’s contributory negligence was 40%. Her claim settled on that basis and, because she was no longer treated as mostly at fault, her entitlement to funded medical treatment continued. The revised figure applied equally to her son’s claim, so the improvement carried across to both.

Our client was riding a scooter across the road when he was struck by another vehicle and suffered serious injuries. He was not wearing a helmet at the time.

The insurer determined that the accident was caused wholly or mostly by our client’s own fault. Under the Motor Accident Injuries Act 2017, a person is treated as mostly at fault where their contributory negligence is greater than 61 per cent, and that finding brings weekly payments of statutory benefits to an end. On the strength of that determination the insurer stopped paying our client’s weekly benefits, leaving him without income support at the very point he was least able to manage without it.

We disputed the determination and the matter was brought before the Personal Injury Commission.

Following negotiations, the insurer accepted that our client was not mostly at fault for the accident. The dispute before the Commission was discontinued and costs were awarded to our client. With the determination reversed, his weekly statutory benefits resumed and the pathway to a common law claim for damages remained open to him.

A family of three were travelling together when another vehicle collided with their car. The impact sent their vehicle into a spin and it struck a pole. All three developed serious psychological injuries as a result of what they went through.

The insurer determined that each of them had sustained a threshold injury. Under the Motor Accident Injuries Act 2017, a psychological or psychiatric injury is a threshold injury if it is not a recognised psychiatric illness. That determination has real consequences. Treatment and income support come to an end after 52 weeks, and section 4.4 of the Act shuts out any claim for damages altogether. For a family still in the middle of treatment, it effectively closes the door on both the help they need and any prospect of compensation.

We requested an internal review of the decision. The result was that the insurer overturned its original determination. Our clients’ entitlement to treatment and care continued beyond the 52 week mark, and the pathway to a claim for damages was opened to them.

Our client injured his left knee at work and lodged a workers compensation claim, which the insurer initially accepted.

The insurer later disputed liability, taking the position that the knee injury had not been caused by his employment. On that basis it stopped funding his treatment and ceased his weekly payments. Causation disputes of this kind are common with knee, shoulder and back injuries, because insurers frequently argue that what the worker is experiencing is degenerative change that would have developed regardless of the job. The question the law asks is whether the employment was a substantial contributing factor to the injury, and answering it properly takes medical evidence directed squarely at that issue.

We arranged for our client to be examined by an independent medical examiner of our own. That doctor concluded that the left knee injury had been caused by our client’s work duties, and he addressed the insurer’s medical report directly, explaining where and why he disagreed with it.

We then asked the insurer to review its decision and provided that report in support. The insurer accepted the position we put and overturned its original determination. Our client’s treatment was reinstated and his weekly payments resumed.

Our client lodged a workers compensation claim which the insurer accepted, and weekly payments began.

As the claim progressed, his capacity for work reduced. The insurer did not accept that, and kept assessing his weekly payments on the basis of a capacity it said he still had.

We arranged for our client to be examined by an independent medical examiner. The report supported his account of his reduced capacity, and it went further than stating a conclusion: it explained what had caused the deterioration and set out the clinical reasoning behind it. That is what gives a report of this kind its weight.

Once that evidence was put to the insurer, it withdrew its original decision. Our client’s weekly payments were adjusted to reflect his actual capacity, and the insurer back paid the shortfall that had built up in the meantime.

Our client sustained tears as a result of a motor vehicle accident. Because there had been a delay in obtaining MRI scans, the causal link between the tears and the accident became the central issue in the claim.

The medical assessor at the Personal Injury Commission accepted that the tears were caused by the accident. The insurer then lodged a review application, arguing that the assessor had not explained why the tears were causally related to the collision. The Commission was satisfied that there was reasonable cause to suspect the medical assessment was incorrect in a material respect, and the matter was referred to a Review Panel for reassessment.

On review, we submitted that our client had complained of the relevant symptoms shortly after the accident and that the forces involved in the collision were capable of producing the tears. The Review Panel accepted those submissions and rejected the insurer’s argument that there was no mechanical explanation for a tear of that kind. It concluded that, on the balance of probabilities, the tears were caused by the accident.

The Review Panel’s determination confirmed that the injuries fell outside the threshold injury definition, which opened the door to a claim for damages.

Our client is a labourer who developed injuries to his cervical spine and shoulder from repetitive work carried out over many years. Injuries of this kind build up gradually rather than arising from a single incident, which often makes them harder to establish and easier for an insurer to argue about.

The insurer arranged for him to be examined by its own independent medical examiner, who assessed his whole person impairment at 9%. That figure carried significant consequences. Under section 66 of the Workers Compensation Act 1987, lump sum compensation for permanent impairment is only payable where impairment from a physical injury is greater than 10%. Section 151H sets a higher bar again, requiring at least 15% before a claim for work injury damages can be brought against an employer. At 9% our client fell below both. He was entitled to neither.

The gap between 9% and 15% is narrow on paper and enormous in practice. It is the difference between a claim that ends with weekly payments and medical expenses, and one that can also deliver a lump sum and a common law claim against the employer for past and future economic loss.

We lodged an application with the Personal Injury Commission so that the degree of impairment could be assessed independently. The medical assessor determined that our client’s whole person impairment was 16%, well above both thresholds. He became entitled to lump sum compensation for permanent impairment, and the pathway to a work injury damages claim was opened to him.

Our client, aged 62, was a passenger in a motor vehicle accident and sustained multiple injuries. He was not working at the time, so no claim for economic loss was available. A PIC medical assessor then certified his physical injuries at 0% whole person impairment, which closed off non-economic loss as well.

At that point the claim was worth nothing, and it would have stayed that way. A certificate is only reviewed if someone reads it closely enough to see what is wrong with it.

We did, and found several material errors in the assessment. We applied for review on that basis. PIC accepted there was reasonable cause to suspect the assessment was incorrect in a material respect and referred the matter to a Review Panel. The Panel revoked the original certificate and assessed the client at 15% whole person impairment.

The claim resolved at $350,000. Without the review, it would have resolved at nil.

We are not doctors, but we have read enough of these assessments to know when one does not hold up against the Guidelines or against the evidence on the file. This one did not.

Our client sustained serious psychological injuries in a motor accident. The extent of those injuries was disputed and the matter was referred to the Personal Injury Commission for medical assessment.

Whole person impairment matters a great deal in a motor accident claim. Under section 4.11 of the Motor Accident Injuries Act 2017, damages for non economic loss, meaning pain, suffering and loss of enjoyment of life, cannot be awarded unless permanent impairment is greater than 10%. Above that line, the figure continues to matter, because the degree of impairment is central to how the claim is valued.

The medical assessor at the Commission determined that our client had a whole person impairment of 19% as a result of his psychological injuries.

The insurer applied for a review of that assessment and the matter was referred to a Review Panel. Applications of this kind are made by insurers in the hope of a lower figure, but a review is a fresh assessment rather than an appeal, and the panel is not confined to reducing the original result. Having reassessed our client, the Review Panel determined that his whole person impairment was 21%. The insurer’s own application left our client in a better position than the one it had challenged.