What Happens to Treatment Funding When a CTP Insurer Changes the Assessor?
A change in the claims assessor or case manager by a CTP insurer does not automatically affect the funding of treatment costs in a motor accident claim in New South Wales. The insurer remains responsible for providing funding for reasonable and necessary treatment under the Motor Accident Injuries Act 2017, regardless of which individual manages the claim. The change in assessor is a procedural matter within the insurer’s internal process and does not alter the legal obligation to fund treatment, as long as the treatment remains appropriate and supported by medical evidence.
How the CTP System Manages Assessor Changes and Treatment Funding
Under the NSW CTP scheme, the insurer is required to fund treatment that is reasonable and necessary for injuries arising from a motor accident. This obligation continues even if the insurer appoints a new assessor to manage the claim. The role of the assessor is to administer the claim, assess entitlements and approve treatment, but they do not determine whether treatment is fundable. That decision rests with the insurer’s clinical review processes and the medical evidence provided by the claimant’s treating practitioner.
SIRA (the State Insurance Regulatory Authority) oversees the CTP scheme and ensures that insurers comply with their legal obligations, including the provision of treatment funding. If a claimant believes that a change in assessor has led to a delay or refusal in funding for treatment, they may raise a concern with the insurer and, if unresolved, seek intervention through SIRA’s dispute resolution processes. SIRA does not appoint assessors, but it can review whether an insurer’s decision to refuse or delay treatment funding is consistent with the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines.
Practical Steps if an Assessor Change Affects Treatment Funding
If a claimant experiences a change in assessor and notices a delay in treatment approval or funding, the following steps may help protect their rights:
- Immediately notify your treating medical practitioner of the change and request that they confirm in writing the medical necessity of the treatment being sought.
- Obtain a copy of any correspondence from the insurer regarding the change in assessor, including any notice of refusal or delay in funding.
- Keep all records of treatment, including invoices, appointment notes, and reports from your medical practitioner.
- If treatment funding is delayed or refused, contact the insurer’s claims team to request a written explanation and to request a review of the decision.
- If the insurer does not respond satisfactorily, you may contact SIRA to raise a dispute. SIRA provides a formal process for resolving disagreements about treatment funding, including those arising from changes in claim management.
Disputes and SIRA’s Role in Resolving Funding Issues
SIRA has a formal dispute resolution process for motor accident claims. If a claimant believes that a change in assessor has led to an unjustified delay or refusal in treatment funding, they can apply to SIRA for a review. SIRA will assess whether the insurer’s decision was consistent with the law and the Motor Accident Guidelines. The authority may require the insurer to reinstate funding, approve previously refused treatment, or provide a detailed explanation for the decision.
SIRA’s role is not to replace the assessor, but to ensure that the insurer’s actions comply with statutory obligations. The authority may also investigate systemic issues if multiple claimants report similar problems following an assessor change. However, SIRA does not have the power to force an insurer to appoint a specific assessor or to override clinical decisions made by medical practitioners.
When to Seek Independent Advice
A change in assessor alone does not justify a claim for compensation or a legal challenge. However, if a claimant experiences a pattern of delays, inconsistent decisions, or a refusal of treatment that is supported by medical evidence, it may be appropriate to seek independent legal or medical advice. This is particularly important if the claimant has a complex injury, a history of prior treatment, or if the insurer is disputing the necessity of treatment.
A hypothetical example: A claimant in Sydney was receiving physiotherapy for a neck injury following a car crash. After the insurer changed assessors, the new assessor delayed approving a follow-up appointment for three weeks, despite a letter from the physiotherapist confirming ongoing treatment was necessary. The claimant contacted SIRA, provided medical evidence, and SIRA required the insurer to reinstate funding and approve the treatment within seven days. The change in assessor did not affect the legal right to treatment, but the delay was addressed through SIRA’s dispute process.
Next Steps and When to Act
The legal obligation to fund treatment remains in place regardless of who manages the claim. However, delays or inconsistencies in funding following an assessor change may indicate a need for intervention. Time limits apply to certain claims, and it is important to act promptly if you believe your treatment funding has been unfairly affected.
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