Insurer Denial of Treatment Funding in NSW CTP Claims
If your insurer has denied funding for treatment costs following a motor accident in Bankstown, New South Wales, you are not without recourse. Under the Motor Accident Injuries Act 2017, you may still be entitled to treatment and care benefits, even if the insurer disputes liability or the need for specific treatment. The decision to fund treatment is governed by clear legal standards, and a denial does not necessarily mean the treatment will not be funded.
Legal Framework for Treatment and Care Benefits
Treatment and care benefits are a statutory entitlement under the Motor Accident Injuries Act 2017. These benefits cover reasonable and necessary treatment for injuries sustained in a motor accident, including medical consultations, physiotherapy, psychological services, and rehabilitation. The insurer must fund these costs if they are directly related to the accident and meet the criteria set out in the Motor Accident Injuries Regulation 2017.
An insurer may deny funding on grounds such as: the treatment is not related to the accident, the injury does not meet the threshold for benefits, or the treatment is not considered reasonable or necessary. However, the insurer must provide a written reason for the denial, and the decision can be challenged through formal dispute resolution processes.
Practical Steps if Treatment Funding Is Denied
If your insurer refuses to fund treatment, take the following steps:
- Obtain a written statement from your medical practitioner confirming that the treatment is necessary and directly related to your accident injury.
- Gather all supporting evidence, including medical reports, treatment plans, invoices, and correspondence with the insurer.
- Notify the insurer in writing of your disagreement and request a review of the decision.
- Contact the Motor Accident Injury Scheme (SIRA) if the insurer does not respond or continues to deny funding.
SIRA is the independent body responsible for administering the CTP scheme in NSW. It has the authority to review insurer decisions and determine whether treatment should be funded.
How SIRA Resolves Disputes Over Treatment Funding
SIRA provides a formal dispute resolution process for claims where an insurer has denied or refused to fund treatment. You can apply to SIRA to review the insurer’s decision. SIRA will assess whether the treatment is reasonable and necessary in relation to the accident injury, based on medical evidence and the Motor Accident Injuries Guidelines.
SIRA may order the insurer to fund the treatment if it finds that the treatment meets the statutory criteria. The process is free for claimants and does not require legal representation. However, it is important to act promptly, as delays may affect the outcome.
Time Limits and Procedural Requirements
There is no strict time limit for applying to SIRA to review a decision on treatment funding. However, it is best to act as soon as possible after a denial to preserve evidence and ensure timely access to treatment. Delays may make it more difficult to obtain medical records or confirm the connection between the injury and the accident.
If you have not already done so, you must notify the insurer of your claim within 6 months of the accident. Failure to do so may affect your ability to claim benefits, including treatment and care benefits.
When to Seek Independent Advice
While SIRA provides a free review process, complex medical evidence or disputes involving threshold injuries may require independent legal advice. This is particularly relevant if:
- The insurer disputes that your injury is related to the accident.
- Your injury involves a spinal nerve-root condition with neurological signs other than radiculopathy, which may still qualify as a threshold injury under the Motor Accident Injuries Guidelines.
- You are seeking funding for treatment that is not routinely covered, such as specialist surgery or long-term rehabilitation.
A solicitor experienced in motor accident claims can help you prepare a strong case and represent you in any formal review or dispute process.
Hypothetical Example: Treatment Funding Dispute in Bankstown
A 38-year-old resident of Bankstown was involved in a motor vehicle accident on 12 May 2026. She sustained soft tissue injuries to her neck and back. Her treating physiotherapist recommended a 12-week course of manual therapy and exercise-based rehabilitation. The CTP insurer denied funding on the grounds that the injury was not severe enough to warrant treatment beyond basic medical care.
The claimant obtained a written medical report confirming the treatment was necessary and related to the accident. She submitted the report to SIRA, which reviewed the case and determined that the treatment was reasonable and necessary. SIRA directed the insurer to fund the full course of physiotherapy.
Next Steps: Requesting Contact About Your Circumstances
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.