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 an NSW CTP insurer delays funding treatment costs after a motor accident, claimants may face financial strain and disrupted recovery. Under the Motor Accident Injuries Act 2017, insurers must act within set timeframes to approve or reject claims. Delays can breach these rules, allowing claimants to challenge decisions through SIRA or legal action. This article explains how to address delayed funding, what evidence matters, and the legal limits on insurer timelines.
What Happens When an Insurer Delays Funding?
CTP insurers are legally required to respond to treatment cost claims within 28 days of receiving a completed claim form, per SIRA guidelines. If an insurer fails to act within this period, it may be considered a breach of duty. Delays can prevent injured persons from accessing essential treatments, such as physiotherapy or specialist consultations, while they wait for approval.
Insurers may also delay decisions to reassess claims, request additional documentation, or investigate alleged overclaims. While some delays are justified (e.g., verifying medical necessity), prolonged inaction without explanation can hinder recovery. Claimants should document all communication with insurers, including dates, correspondence, and any refusal to fund specific treatments.
How to Challenge Delayed Funding Decisions
Claimants can escalate disputes by contacting SIRA’s claims team directly. SIRA provides a formal process for resolving disagreements about treatment funding, including reviewing medical evidence and insurer decisions. If an insurer refuses to fund a treatment deemed necessary by a medical practitioner, claimants should:
- Request a written explanation for the delay
- Submit supporting medical records
- Lodge a formal dispute with SIRA
In cases of prolonged delays, claimants may also seek legal advice to explore options such as applying to the NSW Civil and Administrative Tribunal (NCAT) for an order compelling the insurer to act. Legal representatives can help claimants understand whether delays constitute a breach of statutory obligations under the Motor Accident Injuries Act 2017.
Legal Limits on Insurer Timelines
Insurers must act promptly under the following rules:
- 28-day response period: Insurers must respond to claims within 28 days of receiving a completed claim form. Failure to act within this timeframe may allow claimants to argue the insurer has unreasonably delayed funding.
- 52-week statutory benefits: If treatment costs are approved, weekly income payments and treatment benefits are generally limited to 52 weeks after the accident, unless the injury meets specific impairment thresholds.
- Threshold injury rules: For soft-tissue injuries (e.g., whiplash), insurers may limit funding after 52 weeks unless the injury meets the spinal nerve-root criteria outlined in the Motor Accident Guidelines. Delays in approving treatment for such injuries could affect access to benefits.
Practical Steps for Claimants in Auburn
- Keep detailed records: Document all interactions with insurers, including dates, times, and the nature of communications. Save copies of medical reports, invoices, and correspondence.
- Seek medical evidence: Obtain written confirmation from a medical practitioner that the treatment is necessary and directly related to the accident.
- Escalate disputes: Contact SIRA’s claims team to challenge delays. Use the 'Making a motor accident claim' page on SIRA’s website for guidance on dispute resolution.
- Consult a legal professional: If delays persist beyond 28 days or impact access to treatment, seek advice from a solicitor specialising in CTP claims. Legal representatives can assess whether the insurer’s actions breach statutory timeframes.
Example Scenario
Consider a claimant in Auburn who sustained a soft-tissue injury in a car accident. The insurer delays approving physiotherapy treatment for 30 days, during which the claimant cannot afford sessions. The insurer later refuses to fund the treatment, claiming it is not 'threshold' injury. The claimant can challenge this by:
- Submitting medical evidence showing the injury meets the spinal nerve-root criteria
- Demonstrating the insurer’s 28-day delay breached its duty to act promptly
- Requesting a review by SIRA or NCAT
When to Seek Legal Advice
Claimants should consult a solicitor if:
- The insurer refuses to fund treatment deemed necessary by a medical practitioner
- Delays exceed 28 days without a valid explanation
- The claimant faces financial hardship due to unapproved treatment
- The insurer disputes the injury’s classification as a threshold injury
Next Steps
CTP insurers must act within set timeframes to fund treatment costs. Delays can disrupt recovery and access to essential care. By documenting interactions, seeking medical evidence, and escalating disputes through SIRA, claimants can challenge unjustified delays. For personalised guidance on your circumstances, complete the quick, no obligation enquiry form.