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 NSW Compulsory Third Party (CTP) insurer has denied coverage for treatment costs, you're not alone. Insurers often reject claims by arguing the treatment isn't 'reasonably necessary' or falls outside the Motor Accident Injuries Act 2017 (MAIA). This article explains how insurers handle such denials, what SIRA guidelines say about treatment cost funding in Illawarra and South Coast, and steps you can take to challenge a refusal.
How NSW CTP Insurers Typically Deny Treatment Cost Claims
Insurers may deny coverage for treatment costs by claiming the therapy or medical service isn't 'reasonably necessary' for recovery. Under the MAIA, treatment must be 'reasonably necessary' to address the injury caused by the accident. For example, an insurer might reject physiotherapy if they claim your injury has 'fully recovered' or the treatment isn't listed in the Motor Accident Guidelines.
SIRA's guidelines clarify that 'reasonably necessary' means the treatment must be: (1) directly related to the injury, (2) medically appropriate, and (3) not excessive. Insurers may also deny coverage if they believe the treatment cost exceeds the 'reasonable cost' threshold, even if the treatment is necessary.
What SIRA Says About Treatment Cost Funding in Illawarra and South Coast
SIRA's Motor Accident Claims page confirms that treatment cost funding is available under the MAIA, regardless of location within NSW. However, insurers may challenge claims by arguing the treatment isn't 'reasonably necessary' or the cost isn't 'reasonable.' For example, an insurer might deny coverage for a specialist consultation if they claim the specialist isn't 'reasonably necessary' for your injury.
In Illawarra and South Coast, claimants should note that SIRA's guidelines apply uniformly. If your insurer denies coverage, you must provide evidence that the treatment meets the 'reasonably necessary' standard. This includes medical reports, treatment plans, and cost breakdowns.
Steps to Take if Your Treatment Cost Funding is Denied
- Review the Denial Letter: Insurers must provide a written explanation for denying your claim. Check if they've cited the 'reasonably necessary' standard or other MAIA provisions.
- Gather Evidence: Collect all medical records, treatment plans, and cost documentation. SIRA's 'What You Can Claim' page lists eligible treatment costs, including physiotherapy, specialist consultations, and medication.
- Dispute the Decision: If the insurer's denial is based on a misunderstanding, you can request a review. SIRA provides a formal process for disputing decisions, including submitting additional evidence.
- a Seek Independent Medical Advice: If your insurer disputes the necessity of your treatment, consider getting a second opinion from a medical practitioner. This can help demonstrate the treatment's validity.
Time Limits and Next Steps
Under the MAIA, you have 52 weeks from the accident date to claim certain benefits, including treatment cost funding. If your claim is denied after this period, you may need to pursue a dispute through SIRA's internal review process.
If your insurer refuses to fund your treatment costs, contact LegalAdvice.com.au for assistance. Our team can help you understand your options and ensure your claim meets the legal requirements.
When to Seek Legal Advice
If your insurer denies your claim and you're unsure how to respond, consider consulting a solicitor. Legal professionals can help you: (1) challenge the insurer's decision using MAIA provisions, (2) navigate SIRA's dispute process, and (3) ensure your claim meets all legal requirements.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.