How Insurers Can Legally Deny 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).
Insurers may deny funding for treatment costs in NSW Compulsory Third Party (CTP) claims if they believe the treatment is not necessary, not related to the accident, or does not meet the scheme’s requirements. Under the Motor Accident Injuries Act 2017, insurers must fund treatment that is reasonably necessary for the injury caused by the accident. However, they can refuse to cover costs if the treatment falls outside these criteria.
For example, an insurer might deny funding if the treatment is for a pre-existing condition, not directly linked to the accident, or if the medical evidence does not support the necessity of the treatment. SIRA’s guidelines (https://www.sira.nsw.gov.au/claims/motor-accidents/what-you-can-claim) clarify that treatment must be directly related to the injury and that the insurer must assess its reasonableness.
Practical Steps to Challenge a Funding Denial in Ballina NSW
If your CTP claim is denied for treatment funding, take the following steps:
- Request a detailed explanation from the insurer, including the specific reasons for the denial.
- Provide medical evidence such as reports from your treating practitioner confirming the treatment’s necessity.
- Follow SIRA’s process for disputing decisions. You can submit a written objection to the insurer, referencing the Motor Accident Injuries Act 2017 and SIRA’s guidelines.
- Seek independent medical opinion if the insurer’s assessment conflicts with your treating practitioner’s findings.
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident under the Motor Accident Injuries Act 2017 s 4.4. However, disputes about treatment funding can extend beyond this period if the insurer’s decision is appealed. You can escalate disputes through the NSW Civil and Administrative Tribunal (NCAT) or the NSW Supreme Court, depending on the claim’s complexity.
When to Seek Legal Advice
If the insurer’s denial is based on a misunderstanding of the scheme’s rules, or if you believe the treatment is necessary but the insurer is refusing to fund it, consult a solicitor. Legal advice can help you challenge the denial using the correct legal framework and ensure your rights under the CTP scheme are protected.
Example: Challenging a Funding Denial
Consider a claimant in Ballina who was denied funding for physiotherapy after a car accident. The insurer argued the treatment was not “reasonably necessary.” The claimant submitted a medical report stating the physiotherapy was critical to prevent long-term mobility issues. By referencing SIRA’s guidelines and the Act, the claimant successfully disputed the denial and secured funding.
Next Steps
CTP funding disputes often hinge on the strength of medical evidence and adherence to the scheme’s rules. If you’re unsure how to proceed, complete the quick, no obligation enquiry form to request contact about your circumstances. Every claim depends on its own facts.