When a CTP Insurer Changes the Assessor
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 CTP insurer replaces the claims assessor or case manager assigned to your motor accident claim, it can impact how treatment costs are funded. Under NSW law, the insurer must provide a valid reason for the change and ensure the new assessor follows the same legal framework. This process is governed by the Motor Accident Injuries Act 2017 and SIRA guidelines.
How Assessor Changes Affect Funding
SIRA (State Insurance Regulatory Authority) oversees funding decisions for treatment costs under the CTP scheme. If an insurer changes assessors, it may reassess whether your treatment is 'reasonably necessary' or 'cost-effective' under the Motor Accident Guidelines. This can delay or reduce funding for therapies like physiotherapy, psychology, or medical equipment.
For example, if a new assessor concludes your treatment is not 'cost-effective' after 52 weeks, funding may stop even if your injuries are ongoing. This is because the 52-week statutory benefit period applies only to 'threshold injuries' under the Act. If your claim involves a whole-person impairment rating, funding rules change significantly.
Steps to Take if an Assessor is Changed
- Request written reasons for the assessor change from the insurer. Under NSW law, insurers must justify changes to the claims process.
- Review the new assessor’s report to ensure it follows SIRA’s guidelines on treatment necessity. Look for clinical evidence supporting the funding decision.
- Seek independent medical advice if you believe the new assessor’s opinion is biased or incomplete. A treating medical practitioner can provide evidence to challenge the assessment.
- Submit a formal dispute to SIRA if the funding decision is unfair. SIRA has a formal process for resolving disputes over treatment funding and assessor changes.
Time Limits and Dispute Options
CTP insurers must respond to disputes within 28 days under the Motor Accident Injuries Regulation 2017. If the insurer fails to act within this timeframe, you may need to escalate the matter to SIRA or seek legal advice. Note that time limits apply differently depending on whether the dispute involves treatment funding, weekly benefits, or impairment assessments.
When to Seek Legal Advice
If the insurer refuses to fund essential treatment, changes assessors without justification, or delays your claim beyond 52 weeks, you should consult a solicitor. Legal advice is particularly important if your claim involves a whole-person impairment rating or if the insurer disputes the necessity of your treatment.
Practical Example
Consider a claimant on the Central Coast who requires ongoing physiotherapy after a car accident. If the insurer replaces the assessor and stops funding after 52 weeks, the claimant must prove that their injuries meet the 'threshold injury' definition under the Act. If they have a whole-person impairment rating of 10% or more, funding for treatment should continue beyond 52 weeks under the CTP scheme.
Next Steps
CTP funding decisions depend on the accident date, injury type, and insurer actions. If you’re unsure whether your claim is being handled fairly, complete the quick, no obligation enquiry form to request contact about your circumstances. Every claim depends on its own facts.