CTP Insurer Change of Assessor and Funding for Treatment Costs
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).
If a NSW CTP insurer replaces your assigned medical assessor without prior notice, it can disrupt treatment funding for your claim. Under the Motor Accident Injuries Act 2017 and SIRA guidelines, insurers must follow specific rules when changing assessors. This article explains how such changes impact funding, what evidence matters, and steps to challenge unfair decisions.
Why CTP Insurers May Change Assessors
- CTP insurers are required to fund treatment costs under the
- Motor Accident Injuries Act 2017* and SIRA guidelines. If an insurer believes the current assessor is unsuitable, such as lacking expertise in your injury type, they may request a replacement. However, the insurer must provide a valid reason and notify you before making changes. SIRA’s
- Making a Motor Accident Claim* page states insurers must “cooperate with claimants to ensure treatment is funded appropriately.”
How Assessor Changes Affect Funding
A change of assessor can delay or reduce funding for treatment costs, including physiotherapy, scans, or specialist consultations. SIRA’s What You Can Claim page clarifies that treatment funding is based on the assessor’s report, so a new assessor may reassess the necessity or cost of care. For example, if a new assessor deems a scan unnecessary, funding for it may be denied.
Practical Steps for Claimants in Bankstown
- Request Written Reasoning: If an insurer changes assessors, ask for a written explanation of why the change is necessary. SIRA guidelines require insurers to provide “clear and reasonable justification” for such decisions.
- Review Medical Records: Ensure your treating doctors provide detailed records showing the necessity of treatment. SIRA’s Motor Accident Claims page notes that “medical evidence is critical to support funding decisions.”
- Challenge Unreasonable Changes: If the assessor change appears arbitrary, you may dispute it through SIRA’s dispute resolution process. The insurer must demonstrate the new assessor’s qualifications match the injury type, such as a neurologist for spinal injuries.
Time Limits and Dispute Options
CTP insurers must fund treatment costs within 52 weeks of the accident, unless the injury is classified as a “threshold injury” under the Motor Accident Guidelines. If a change of assessor delays funding beyond this period, it may affect your entitlements. You can request a review of the insurer’s decision through SIRA’s online dispute portal or by contacting the NSW Civil and Administrative Tribunal (NCAT).
Example: A Claimant’s Experience
A claimant in Bankstown sought funding for a MRI scan after a whiplash injury. The insurer initially approved the scan but later replaced the assessor, arguing the scan was “not essential.” The claimant submitted the MRI report and a doctor’s note explaining its necessity, leading the insurer to reinstate funding. This highlights the importance of thorough medical documentation.
When to Seek Legal Advice
If an insurer’s assessor change appears to be a tactic to reduce funding, or if you face delays beyond 52 weeks, consult a solicitor. While SIRA provides free dispute resolution, complex cases may require legal representation to challenge the insurer’s interpretation of guidelines.
Next Steps
CTP insurers must act reasonably when changing assessors, but claimants should take proactive steps to protect treatment funding. Document all communications, ensure medical records are complete, and challenge decisions that appear unfair. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.