What Attendant Care Services Are Covered Under NSW CTP Claims
If you have sustained a serious injury in a motor accident in New South Wales, you may be entitled to compensation for attendant care services. These are paid services that provide personal care and supervision to assist you with daily living tasks such as bathing, dressing, preparing meals, and managing medication. The Motor Accident Injuries Act 2017 allows for compensation for attendant care when it is reasonably necessary due to injury-related functional limitations. This includes services provided by a registered care provider, a family member, or a professional carer. The entitlement is not limited to formal care agencies, support from a family member who provides care on a regular basis may also be considered, provided it is documented and not duplicative of services already funded under other arrangements.
How the PIC Assesses the Need for Attendant Care in Disputes
The Personal Injury Commission (PIC) does not directly assess claims. Instead, the insurer (often referred to as the CTP insurer or PIC in practice) is responsible for evaluating whether attendant care services are reasonable and necessary. In disputes, the insurer will review medical evidence, including reports from your treating medical practitioner and any independent medical assessment, to determine if the care is required and whether the type, frequency, and cost are appropriate. The insurer may challenge the need for care if it considers the injury does not significantly impair your ability to perform daily activities independently. They may also dispute the cost of care, particularly if it exceeds standard rates for similar services in the community.
What Claimants Should Do If the PIC Disputes Care Services
If your insurer disputes the need for attendant care services, you have several practical steps to take. First, ensure that all medical evidence clearly links your injury to the need for care. This includes a detailed report from your treating medical practitioner outlining your functional limitations and the specific care tasks you cannot perform. You should also keep records of all care provided, including invoices, timesheets, and written confirmations from the care provider. If the insurer refuses to approve a service, you may request a formal review under the insurer’s internal dispute resolution process. This must be done within a reasonable timeframe, typically within 28 days of receiving a rejection notice.
If the internal review does not resolve the dispute, you may apply to the Personal Injury Commission (PIC) for a determination. The PIC will assess whether the care is reasonable and necessary based on the evidence provided. You must submit all relevant documentation, including medical reports, care logs, and financial records. The PIC will not automatically accept a family member’s care as compensable, there must be evidence that the care is not provided as part of normal family support and that it would otherwise need to be purchased commercially.
How SIRA’s Guidance Influences PIC Decisions on Care Services
The State Insurance Regulatory Authority (SIRA) provides guidance on the assessment of attendant care services through its Motor Accident Injuries Act 2017 and associated Motor Accident Guidelines. SIRA’s position is that care must be reasonable and necessary in the context of the injury and not excessive or disproportionate. The PIC is expected to assess care needs based on the actual functional impact of the injury, not on assumptions about lifestyle or convenience. For example, if an injury results in a loss of mobility that prevents you from leaving your home without assistance, care that supports safe mobility and daily independence may be approved.
SIRA also emphasises that care services should not duplicate benefits already received under other schemes, such as the National Disability Insurance Scheme (NDIS), or under workers’ compensation. If you are receiving care through another scheme, the CTP insurer may seek to offset or reduce the CTP claim accordingly. However, the insurer must not deny a claim solely because another scheme is involved, each scheme operates under separate legal principles.
Practical Evidence That Matters in Dispute Resolution
The following evidence is critical when disputing a decision about attendant care services:
- A medical report from your treating practitioner detailing functional limitations and the need for assistance with at least two daily activities
- A care plan outlining the frequency, duration, and nature of care required
- Invoices or receipts for care services, including provider registration details
- A record of care hours, including dates and times, particularly if care is provided by a family member
- Evidence that the care provider is not a family member who would otherwise provide care without compensation
A hypothetical example: A 42-year-old woman sustained a spinal injury in a car accident that left her unable to transfer from bed to wheelchair independently. Her doctor confirmed she requires assistance with 12 hours of care per week. The insurer initially refused to pay for a professional carer, arguing that her partner could provide care at no cost. The claimant submitted a medical report, a care plan, and a record of 10 hours of care provided by a registered carer over three weeks. The PIC accepted the evidence and approved compensation for 12 hours per week at the standard rate.
Time Limits and Dispute Pathways
There are time limits that apply to disputes about attendant care services. You must apply to the Personal Injury Commission within 12 months of the insurer’s final decision on your claim. If you do not apply within this timeframe, you may lose the right to have the dispute determined by the PIC. The internal review process must be completed within 28 days of receiving a rejection. If the insurer fails to respond within that period, you may proceed directly to the PIC.
The PIC’s medical dispute pathway allows for a review of medical evidence if you believe the insurer’s assessment is incorrect. This process is not automatic and must be formally requested. The PIC will not change a decision simply because you disagree, there must be new or additional medical evidence to support a different conclusion. You may also seek independent medical assessment if the insurer refuses to fund one.
Next Steps for Claimants
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.