How SIRA Assesses Funding for Treatment Costs in NSW CTP 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).
In New South Wales, the State Insurance Regulatory Authority (SIRA) oversees the assessment of treatment costs for Compulsory Third Party (CTP) motor accident claims. Under the Motor Accident Injuries Act 2017, insurers must fund reasonable medical treatment costs, including specialist consultations, therapy, and medications, provided they are directly related to the injury. SIRA’s guidelines emphasize that treatment must be necessary, clinically appropriate, and supported by medical evidence.
For rural and remote areas, SIRA considers additional factors. If an injured person requires specialist care unavailable locally, travel costs and time may be factored into the assessment. For example, a claimant needing a specialist in Sydney from a remote town may have their travel expenses included, as the treatment is deemed essential. However, SIRA does not cover non-essential treatments, such as cosmetic procedures or therapies with limited clinical evidence.
Special Considerations for Rural and Remote NSW
In rural areas, access to healthcare services can delay treatment, which may impact funding decisions. SIRA evaluates whether the treatment delay was unavoidable and whether the injury would have worsened without timely care. For instance, a pedestrian injured in a car park in a remote community may need to travel long distances for surgery, and SIRA may approve additional costs for this.
Insurers also consider the availability of local healthcare providers. If a treatment is not available in the area, the cost of specialist care is more likely to be funded. However, SIRA may reject claims for treatments that could have been provided locally at a lower cost. For example, a claimant with a minor soft-tissue injury treated by a local GP may not qualify for specialist physiotherapy if the injury does not meet the threshold injury criteria under the Motor Accident Guidelines.
How Insurers Determine Funding for Treatment Costs
Insurers assess treatment costs by reviewing medical records, invoices, and clinical notes. They must ensure the treatment aligns with the injury’s severity and is not excessive. For example, if a claimant requires 12 weeks of physiotherapy for a threshold injury, the insurer may fund the full cost, but after 52 weeks, benefits may be limited under s 4.4 of the Motor Accident Injuries Act 2017.
In rural areas, insurers may also consider the cost of travel and accommodation for treatment. However, SIRA does not cover expenses like private transport unless they are medically necessary. A hypothetical example: a cyclist injured in a car park in a remote area may need to travel to a regional hospital for surgery. The insurer would fund the travel cost but may not cover a private ambulance unless it was the only option.
Practical Steps and Evidence to Gather
To support a treatment cost claim, injured persons should collect:
- Medical records confirming the injury’s nature and treatment
- Itemized invoices for all services
- Evidence of travel costs (e.g., receipts for transport)
- Statements from healthcare providers explaining the necessity of treatment
Insurers may request additional information if they dispute the cost. For example, if a claimant seeks funding for a 12-week therapy program, the insurer may ask for clinical evidence showing the treatment’s necessity.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident, though extensions may apply for complex cases. If an insurer refuses to fund treatment costs, the claimant can request a review through SIRA. In some cases, legal advice may be needed to challenge a decision, especially if the claimant believes the assessment was incorrect.
When to Seek Legal Advice
If an injured person is unsure whether their treatment costs will be funded, or if their claim is denied, they should seek legal advice. A solicitor can help challenge an insurer’s decision or negotiate a fair settlement. Legal assistance is particularly valuable in rural areas where access to legal resources may be limited.
Next Steps
CTP funding decisions depend on the injury’s nature, the treatment’s necessity, and the location of the accident. In rural and remote NSW, additional factors like travel time and specialist availability may influence the outcome. To request contact about your circumstances, complete the quick, no obligation enquiry form.