How NSW CTP Insurers Evaluate Attendant Care Claims
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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).
NSW Compulsory Third Party (CTP) insurers assess claims for attendant care services based on medical evidence, necessity, and compliance with the Motor Accident Injuries Act 2017. Attendant care refers to paid assistance with daily living tasks like dressing, bathing, or meal preparation, typically available for injuries meeting the 'threshold injury' criteria under the scheme. Insurers evaluate whether the care is medically necessary, proportionate to the injury, and supported by documented evidence.
Key Factors in Insurer Assessments
Insurers primarily rely on two types of evidence: medical documentation and care provider records. Medical reports must explicitly link the injury to the need for attendant care, often referencing the Motor Accident Guidelines. For example, a doctor might note that a spinal nerve-root injury (as defined in the guidelines) necessitates assistance with mobility. Care providers must also demonstrate that the service is required for the claimant’s recovery, not just convenience.
Insurers may reject claims if the care is deemed non-essential, such as for a minor injury that does not meet the threshold injury definition. They also scrutinise whether the care aligns with the 'only injuries' rule: if a claimant has both threshold injuries and other non-threshold injuries, benefits may not be limited to 52 weeks.
Common Reasons for Claim Rejections
- Insufficient medical evidence: Claims often fail because doctors do not explicitly state the need for attendant care. For instance, a report stating 'the claimant requires assistance with mobility' is stronger than 'the claimant may need help sometimes'.
- Overlapping benefits: If a claimant receives both CTP benefits and workers’ compensation, insurers may question the necessity of duplicate care services.
- Non-compliance with SIRA guidelines: Insurers must adhere to the Scheme Interpretation and Review Authority (SIRA) guidance on what constitutes 'attendant care'. For example, a claimant may need help with personal hygiene but not meal preparation, and insurers will assess whether both are required.
How to Challenge a Denied Claim
If an insurer denies a claim, the claimant can request a review by the NSW Civil and Administrative Tribunal (NCAT). This process involves submitting additional evidence, such as a second opinion from a medical practitioner or updated care records. For example, a claimant might provide a new report indicating that their injury has worsened, necessitating increased assistance.
Practical Steps for Claimants
- Document all care interactions: Keep records of the hours, type of assistance, and any communication with the care provider.
- Request a detailed medical assessment: Ensure the report explicitly links the injury to the need for attendant care.
- Notify the insurer promptly: Delays in reporting care needs may lead to claims being denied as 'not reasonably foreseeable'.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident, though extensions may apply for serious injuries. If a claim is denied, the claimant has 28 days to request a review by NCAT. For example, a claimant who missed the initial deadline due to hospitalisation may need to provide evidence of the delay to qualify for an extension.
Example Scenario
Consider a claimant in Western Sydney who sustained a spinal nerve-root injury after a car accident. Their doctor documents the need for assistance with mobility and personal hygiene. The insurer denies the claim, arguing the injury does not meet the threshold injury criteria. The claimant can challenge this by submitting a revised medical report confirming the injury meets the spinal nerve-root definition in the Motor Accident Guidelines.
When to Seek Legal Advice
Claimants should consult a solicitor if the insurer’s decision is unclear, if the claimant has overlapping injuries, or if the dispute involves complex medical evidence. A lawyer can help navigate NCAT procedures and ensure all claimant records are properly submitted.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.