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).
If an NSW CTP insurer delays funding treatment costs, claimants may face financial strain and legal risks. Under the Motor Accident Injuries Act 2017, insurers must approve treatment funding within specific timeframes. Delays can disrupt recovery and require prompt action to resolve. This article explains how to address delayed decisions, the role of SIRA, and legal steps to challenge insurer delays.
Legal Framework for CTP Funding Decisions
NSW CTP insurers are legally required to assess treatment funding claims within 28 days of receiving all necessary documentation, per SIRA guidelines. If an insurer fails to respond within this period, the claimant may have grounds to escalate the matter. The Motor Accident Injuries Act 2017 (s 4.4) also limits benefits for threshold injuries after 52 weeks, but this does not apply to delayed funding decisions.
Practical Steps for Claimants
- Submit complete medical records promptly to insurers, including treatment plans and invoices. Incomplete submissions often cause delays.
- Track all correspondence with insurers, noting dates and details of requests.
- Request written confirmation of delays. Under NSW law, insurers must provide a reason for delays exceeding 28 days.
- Escalate to SIRA if an insurer fails to respond within 28 days. SIRA can intervene to expedite funding decisions.
SIRA's Role in Resolving Funding Disputes
SIRA oversees CTP claims and has authority to resolve disputes over treatment funding. If an insurer delays approval, claimants can contact SIRA directly to request an internal review. SIRA may also issue a formal notice to the insurer to comply with funding timelines. In complex cases, SIRA can refer disputes to the NSW Civil and Administrative Tribunal (NCAT) for resolution.
Time Limits and Legal Recourse
CTP insurers must act within 28 days of receiving a complete claim. If they fail to respond, claimants can:
- Lodge a complaint with SIRA
- Apply to NCAT for an order compelling the insurer to act
- Seek legal advice to pursue compensation for financial loss caused by delays
When to Seek Legal Advice
Claimants should consult a lawyer if:
- The insurer refuses to fund treatment without justification
- Delays exceed 28 days and disrupt recovery
- The claimant needs to challenge an insurer’s decision to terminate funding
Example Scenario
A car accident victim submits a claim for physiotherapy after a 2023 collision. The insurer delays approval for 35 days, causing the claimant to stop treatment. Under NSW law, the claimant can request SIRA to review the insurer’s delay and seek funding for missed sessions.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.