New South Wales Consolidated Acts New South Wales Consolidated ActsNote : This Schedule sets out merit review matters, medical assessment matters and miscellaneous claims assessment matters for the purposes of Part 7. The assessment of claims is dealt with by Division 7.6.
See section 7.1(2) for the exercise of other miscellaneous functions not included in this Schedule.
The following matters are declared to be merit review matters for the purposes of Part 7--
(a) the amount of statutory benefits that is payable under section 3.4 (Statutory benefits for funeral expenses) or under Division 3.3 (Weekly payments of statutory benefits to injured persons),
(b) whether for the purposes of section 3.12 (Cessation of weekly payments to other injured persons after maximum weekly payments period) an injured person's injury is the subject of a pending claim for damages,
(c) whether for the purposes of section 3.13 (Termination of weekly payments on retiring age) a motor accident that has caused a person's injury has happened before the person has reached retirement age,
(d) the suspension of weekly payments of statutory benefits under section 3.14 (Obligations to provide authorisations and medical evidence), 3.15 (Requirements for evidence as to fitness for work) or 3.17 (Treatment, rehabilitation and vocational training),
(e) whether the insurer has given the required period of notice under section 3.19 (Notice required before discontinuing or reducing weekly payments) before discontinuing or reducing weekly payments of statutory benefits,
(f) whether an amount of statutory benefits is recoverable by the injured person under section 3.19 (3) (Notice required before discontinuing or reducing weekly payments), and the amount of statutory benefits so recoverable,
(g) whether for the purposes of section 3.21 (Weekly statutory benefits to persons residing outside Australia) an injured person is or has been residing outside Australia,
(h) whether the insurer is required to vary an amount of a weekly payment of statutory benefits in accordance with section 3.22 (Indexation of weekly statutory benefits),
(i) whether the cost of treatment and care provided or to be provided to the claimant is reasonable for the purposes of section 3.24(1) (Entitlement to statutory benefits for treatment and care),
(j) whether statutory benefits are payable under section 3.26 (Statutory benefits for loss of capacity to provide gratuitous domestic services), and the amount of statutory benefits so payable,
(k) whether expenses have been properly verified for the purposes of section 3.27 (Verification of expenses),
(n) whether treatment and care expenses have been paid or recovered for the purposes of section 3.29 (No statutory benefits for expenses already compensated),
(p) whether the cost of treatment and care exceeds any limit imposed by the Motor Accident Guidelines for the purposes of section 3.31 (Limits under Guidelines on statutory benefits for particular treatment and care),
(q) whether treatment and care provided to the injured person is treatment and care needs or excluded treatment and care needs to which section 3.32 (No treatment and care statutory benefits for treatment and care needs covered by Lifetime Care and Support Scheme) applies,
(r) whether for the purposes of section 3.33 (Treatment and care provided while persons residing outside Australia) an injured person is an Australian citizen or a permanent resident of Australia or whether treatment and care provided to the injured person has been provided while the person is residing outside Australia,
(s) whether the insurer is entitled to refuse payment of statutory benefits in accordance with section 3.34 (Effect of death on entitlement to statutory benefits), 3.35 (No statutory benefits if workers compensation payable) or 3.36 (No statutory benefits for at-fault driver or owner if vehicle uninsured),
(t) whether the insurer is entitled to refuse payment of statutory benefits in accordance with Part 3 of the Civil Liability Act 2002 (as applied by section 3.39 (Limitation on statutory benefits in relation to certain mental harm)) or 3.40 (Effect of recovery of damages on statutory benefits),
(w) whether the insurer is entitled to delay the making of an offer of settlement under section 6.22 (Duty of insurer to make offer of settlement on claim for damages),
(x) whether for the purposes of section 6.24 (Duty of claimant to co-operate with other party) a request made of the claimant is reasonable or whether the claimant has a reasonable excuse for failing to comply,
(y) whether the claimant has provided the insurer with all relevant particulars about a claim in accordance with section 6.25 (Duty of claimant to provide relevant particulars of claim for damages),
(z) whether the insurer is entitled to give a direction to the claimant under section 6.26 (Consequences of failure to provide relevant particulars of claim for damages),
(za) whether the insurer is entitled to suspend weekly payments of statutory benefits under section 6.5 (Duty of claimants to minimise loss) of the Act,
(aa) whether for the purposes of section 8.10 (Recovery of costs and expenses in relation to claims for statutory benefits) the costs and expenses incurred by the claimant are reasonable and necessary.
The following matters are declared to be medical assessment matters for the purposes of Part 7--
(a) the degree of permanent impairment of the injured person that has resulted from the injury caused by the motor accident (including whether the degree of permanent impairment is greater than a particular percentage),
(b) whether any treatment and care provided or to be provided to the injured person is reasonable and necessary in the circumstances or relates to the injury caused by the motor accident for the purposes of section 3.24 (Entitlement to statutory benefits for treatment and care),
(d) the degree of impairment of the earning capacity of the injured person that has resulted from the injury caused by the motor accident,
(e) whether the injury caused by the motor accident is a threshold injury for the purposes of the Act.
The following matters are declared to be miscellaneous claims assessment matters for the purposes of Part 7--
(a) whether for the purposes of section 2.30 (Claim against Nominal Defendant where vehicle not identified) there has been due inquiry and search to establish the identity of a motor vehicle,
(a1) whether for the purposes of section 2.30 (Claim against Nominal Defendant where vehicle not identified) the person whose death or injury resulted from the motor accident was a trespasser on land that is a road related area open to or used by the public for driving, riding or parking vehicles,
(a2) whether the Nominal Defendant has lost the right to reject a claim under section 2.31 (Rejection of claim for failure to make due inquiry and search to establish identity of vehicle) of the Act for failure to make due inquiry and search to establish the identity of a vehicle,
(b) whether for the purposes of section 3.1 (Statutory benefits payable in respect of death or injury resulting from motor accident) the death of or injury to a person has resulted from a motor accident in this State,
(c) which insurer is the insurer of the at-fault motor vehicle for the purposes of section 3.3 (Determination of relevant insurer),
(d) whether for the purposes of section 3.11 (Cessation of weekly payments after 52 weeks to injured persons most at fault or with threshold injuries) the motor accident concerned was caused wholly or mostly by the fault of the injured person,
(e) whether for the purposes of section 3.28 (Cessation of statutory benefits after 52 weeks to injured adult persons most at fault or to injured persons with threshold injuries) or 3.36 (No statutory benefits for at-fault driver or owner if vehicle uninsured) the motor accident was caused wholly or mostly by the fault of the injured person,
(f) whether the insurer is entitled to refuse payment of statutory benefits in accordance with section 3.37 (No statutory benefits payable to injured person who commits serious driving offence),
(g) whether the insurer is entitled to reduce the statutory benefits payable in respect of the motor accident in accordance with section 3.38 (Reduction of weekly statutory benefits after 12 months for contributory negligence),
(g1) whether for the purposes of Part 5 (Recovery for no-fault motor accidents) a motor accident is a no-fault motor accident,
(h) whether for the purposes of Part 6 (Motor accident claims) the claimant has given a full and satisfactory explanation for non-compliance with a duty or for delay,
(i) whether for the purposes of section 6.9 (Compliance with verification requirements--claim for statutory benefits) or 6.10 (Compliance with verification requirements--claim for damages) the motor accident verification requirements have been complied with,
(j) whether notice of a claim has been given in accordance with section 6.12 (Notice of claims for statutory benefits or damages),
(k) whether the insurer is entitled to refuse payment of statutory benefits, including statutory benefits for a period before a claim is made, in accordance with section 6.13 (Time for making of claims for statutory benefits),
(l) whether a late claim may be made in accordance with section 6.14 (Time for making of claims for damages),
(m) whether a claim may be rejected for non-compliance with section 6.15 (How notice of claims given),
(n) any issue of liability for a claim, or part of a claim, for statutory benefits not otherwise specified in this Schedule.