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 your insurer has denied coverage for treatment costs under your NSW Compulsory Third Party (CTP) claim, you may need to challenge their decision. This article explains how insurers assess funding requests, what treatment costs are covered, and steps to dispute a denial in Albury. NSW law requires insurers to fund reasonable medical treatment related to your injury, but disputes often arise over documentation, injury severity, or eligibility.
What Treatment Costs Are Covered Under NSW CTP Claims?
Under the Motor Accident Injuries Act 2017, insurers must fund treatment costs for injuries resulting from a motor accident. This includes medical consultations, scans, physiotherapy, and specialist care directly related to your injury. SIRA guidelines clarify that treatment must be 'reasonably necessary' and 'directly related' to the accident. For example, if you sustained a soft tissue injury requiring physiotherapy, the insurer must cover those costs.
How Do Insurers Assess Funding Requests?
Insurers evaluate funding requests by reviewing your medical records, treatment plans, and the nature of your injury. They may dispute coverage if:
- The treatment is not listed in the Motor Accident Guidelines
- The injury does not meet the 'threshold injury' definition
- There is a gap between the accident date and treatment start date
- The treatment cost exceeds the insurer's approved schedule
Insurers may also request additional documentation, such as a doctor's statement linking the treatment to your injury.
Steps to Challenge a Funding Denial in Albury
If your insurer denies coverage, take these actions:
- Request a written explanation of why your treatment costs are denied. Insurers must provide reasons under the Motor Accident Injuries Act.
- Submit additional evidence such as medical reports, treatment records, and invoices. Ensure your GP or specialist includes a clear link between your injury and the treatment.
- Dispute the decision by writing to the insurer within 28 days of receiving their response. SIRA's 'Dispute a decision' page provides templates for this.
- Seek independent medical opinion if the insurer questions your injury's severity. A specialist report may clarify your condition.
- Contact SIRA directly if the insurer fails to respond. SIRA can mediate disputes and ensure compliance with the Motor Accident Guidelines.
How SIRA's Guidance Applies to Funding Disputes
SIRA's 'What You Can Claim' page outlines that insurers must fund treatment costs 'reasonably necessary' for your injury. If your insurer disputes coverage, refer to the Motor Accident Guidelines to verify if your treatment meets the 'threshold injury' criteria. For example, if your injury involves a spinal nerve-root injury with neurological signs, it may still qualify as a soft tissue injury under the guidelines.
Time Limits and When to Seek Advice
You have 52 weeks from the accident date to claim certain benefits, but treatment funding disputes can extend beyond this period. If your insurer denies coverage after this time, you may need to demonstrate that your injury requires ongoing treatment. Always act within the 28-day dispute period outlined in the Motor Accident Injuries Act. If your claim involves complex issues like contributory fault or overlapping workers' compensation claims, seek legal advice promptly.
Example: Funding a Physiotherapy Claim
Consider a claimant who sustained a soft tissue injury in a car accident. Their GP refers them to a physiotherapist for treatment. The insurer denies coverage, arguing the injury does not meet the 'threshold injury' definition. The claimant submits the physiotherapist's report, which details the injury's impact on mobility. SIRA reviews the report and confirms the treatment is 'reasonably necessary, ' leading to coverage approval.
Next Steps
CTP funding disputes often hinge on accurate documentation and understanding of the Motor Accident Guidelines. If your insurer denies coverage for treatment costs, act quickly to challenge their decision. For personalized advice, complete the quick, no obligation enquiry form to request contact about your circumstances.