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).
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
If your CTP insurer has denied funding for treatment costs in rural NSW, you may be facing unique challenges due to geographic barriers. This article explains how insurers may legally deny claims, how SIRA guidelines apply to rural claimants, and practical steps to challenge denials while considering accessibility issues.
How Insurers Can Legally Deny CTP Claims for Treatment Costs
Under the Motor Accident Injuries Act 2017, insurers may deny claims if they dispute the injury's eligibility or the treatment's necessity. In rural areas, insurers might argue that:
- The injury does not meet the 'threshold injury' criteria under the Motor Accident Guidelines.
- The treatment is not 'reasonably necessary' for the injury.
- The claimant has not followed the required process for accessing treatment.
Insurers may also reference SIRA's 'What You Can Claim' page to argue that certain treatments are not covered. For example, if a claimant requires specialist care in a regional hospital, the insurer might dispute the cost if they claim it's not 'reasonably necessary' under the guidelines.
SIRA Guidelines and Rural Claimants
SIRA's Motor Accident Guidelines outline what constitutes a threshold injury and what treatment is eligible. For rural claimants, the guidelines emphasize that treatment must be 'reasonably necessary' and 'reasonably available' in the local area. This means insurers cannot automatically deny claims simply because treatment occurs in a remote location.
Key SIRA resources confirm that:
- Rural claimants are entitled to the same treatment funding as urban claimants, provided the treatment is medically necessary.
- Insurers must consider the practical challenges of accessing treatment in remote areas when assessing claims.
- Claimants should document the necessity of treatment, including medical reports and evidence of geographic barriers.
Steps to Challenge a Denied CTP Claim
If your treatment funding is denied, take these practical steps:
- Request a written explanation from the insurer detailing why the claim was denied. This should reference specific sections of the Motor Accident Guidelines.
- Submit additional evidence such as medical records, treatment plans, and proof of geographic barriers (e.g., distance to the nearest specialist).
- Appeal through SIRA's dispute process. Claimants can request a review by the Motor Accident Claims Authority, which may involve an independent assessment.
- Seek legal advice if the insurer refuses to reconsider. A solicitor can help challenge the denial using the SIRA guidelines and the Act.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident, but insurers can dispute claims even after this period if they were not submitted on time. If your claim is denied, act quickly: SIRA's dispute process requires prompt submission of evidence. For rural claimants, delays in accessing treatment or documentation may affect eligibility, so it's crucial to seek advice before the 52-week deadline.
Example: A Rural Claimant's Case
Consider a claimant who suffered a soft-tissue injury in a remote NSW car park. The insurer denied treatment funding, arguing the injury did not meet the threshold criteria. However, under the Motor Accident Guidelines, the claimant's injury qualified as a threshold injury because it involved a spinal nerve-root injury with neurological signs. By submitting medical evidence and demonstrating the necessity of treatment, the claimant successfully challenged the denial.
Next Steps
CTP claim denials in rural NSW can be complex, especially when insurers dispute the necessity of treatment. Understanding the SIRA guidelines and acting quickly are essential. If your claim is denied, complete the quick, no obligation enquiry form to request contact about your circumstances.