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 your CTP claim for treatment costs in New South Wales, you may need to understand the legal rules and steps to challenge the decision. Under the Motor Accident Injuries Act 2017 (MAIA), insurers must fund treatment costs for injuries caused by a motor vehicle accident, but claims can be denied for specific reasons. This article explains how insurers handle treatment funding denials, what evidence matters, and how to respond under NSW law.
Why Insurers Deny CTP Treatment Funding Claims
Insurers often deny treatment cost claims by arguing the injury does not meet the legal definition of a 'threshold injury' or that the treatment is not 'reasonably necessary' under SIRA guidelines. Common reasons include:
- The injury is not listed as a 'threshold injury' in the Motor Accident Guidelines
- The treatment is not deemed 'reasonably necessary' for recovery
- The claimant has not followed the insurer's recommended treatment plan
- The injury is not directly caused by the accident
Under the MAIA, insurers must fund treatment costs for injuries that meet the 'threshold injury' definition. This includes injuries like whiplash, soft tissue injuries, or fractures that require medical treatment. However, insurers may deny claims if they believe the injury does not meet the required criteria.
How SIRA Handles Denied Treatment Funding Requests
The State Insurance Regulatory Authority (SIRA) oversees CTP claims in NSW. If an insurer denies treatment funding, claimants can:
- Request a written explanation of the denial
- Submit additional medical evidence to support the claim
- Apply for a review by SIRA
SIRA's guidelines state that treatment must be 'reasonably necessary' and directly related to the accident. For example, if a claimant requires physiotherapy for a soft tissue injury, the insurer must fund it unless it is deemed unnecessary. Claimants should ensure all medical records clearly link the treatment to the accident.
Practical Steps to Challenge a Denial
If your treatment costs are denied, take these steps:
- Review the denial letter to understand the insurer's reasoning
- Gather medical evidence showing the injury meets the threshold criteria
- Submit a formal request for reconsideration with supporting documents
- Contact SIRA if the insurer refuses to review the claim
Key evidence includes:
- Medical reports confirming the injury and treatment
- Accident reports or witness statements
- Proof of treatment costs (invoices, receipts)
- Documentation of the insurer's refusal to fund the treatment
Time Limits and Dispute Options
CTP claims must be submitted within 52 weeks of the accident under the MAIA. If the insurer denies treatment funding after this period, the claimant may lose the right to seek benefits. However, if the denial occurs before 52 weeks, claimants can challenge it through SIRA.
If the insurer refuses to review the claim, you can:
- Apply for a review by SIRA
- Seek mediation through the NSW Civil and Administrative Tribunal (NCAT)
- Lodge a complaint with the Financial Ombudsman Service (FOS)
When to Seek Legal Advice
If your insurer denies treatment funding and you are unsure how to respond, it is important to seek legal advice. A solicitor can help you:
- Understand your rights under the MAIA
- Challenge the insurer's decision using legal procedures
- Negotiate a fair settlement
Example Scenario
Consider a claimant who suffered a soft tissue injury in a car accident. The insurer denies funding for physiotherapy, arguing the injury does not meet the threshold criteria. The claimant submits medical evidence showing the injury requires treatment and applies for a review. SIRA reviews the evidence and determines the treatment is 'reasonably necessary, ' leading to the insurer funding the costs.
Next Steps
CTP claims involving treatment funding can be complex, especially when insurers deny the claim. Understanding the legal framework and taking the right steps can help you challenge a denial and secure the support you need. If you are unsure how to proceed, complete the quick, no obligation enquiry form to request contact about your circumstances.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.