Insurer Denial of Treatment Funding in NSW CTP Claims
If your CTP insurer in New South Wales has denied funding for treatment costs following a motor accident, you are not without recourse. Insurers may refuse to fund treatment on grounds such as the injury not being directly attributable to the accident, the treatment not being reasonable or necessary, or the claim being outside a time limit. However, under the Motor Accident Injuries Act 2017 (MAIA), you are entitled to treatment and care benefits for injuries arising from a motor accident, provided they are reasonable, necessary, and directly related to the accident. Denials must be based on valid legal grounds and supported by evidence. You have the right to challenge a denial through formal dispute processes administered by the State Insurance Regulatory Authority (SIRA).
Legal Basis for Treatment Funding in NSW
Under the Motor Accident Injuries Act 2017, treatment and care benefits are available to cover reasonable and necessary medical, allied health, and rehabilitation services arising from a motor accident. These benefits are not contingent on proving fault. The insurer must fund treatment if it is clinically appropriate and directly related to an injury sustained in the accident. The Motor Accident Injuries Regulation 2017 and SIRA’s Motor Accident Guidelines set out the criteria for assessing whether treatment is reasonable and necessary. This includes whether the treatment is consistent with accepted medical practice, has a reasonable prospect of improving the injury, and is not excessive or disproportionate.
Common Grounds for Denial and How to Respond
Insurers may deny treatment funding on several grounds, including:
- The injury was pre-existing or unrelated to the accident.
- The treatment is not clinically indicated or lacks medical evidence of necessity.
- The treatment provider is not registered or qualified under the CTP scheme.
- The claimant failed to notify the insurer within the required timeframe.
If your claim is denied, you must first obtain a written explanation from the insurer. This should detail the reasons for the denial and reference the relevant provisions of the MAIA or SIRA guidelines. You may then request a review of the decision from the insurer. If the review is unsuccessful, you can apply to SIRA for a determination under the Motor Accident Injuries Act 2017. SIRA has the authority to assess whether the treatment should be funded and to order the insurer to pay.
Evidence That Supports a Treatment Funding Claim
To challenge a denial, you must gather and submit evidence that demonstrates the treatment is reasonable, necessary, and directly linked to the accident. Key evidence includes:
- A medical report from your treating practitioner stating the injury is related to the accident and that the treatment is clinically appropriate.
- A treatment plan outlining the nature, duration, and expected outcomes of the treatment.
- Records of all treatment sessions, including dates, procedures, and notes.
- A letter from your medical practitioner confirming the treatment is not for the management of a pre-existing condition.
- Photographic or video evidence of the accident scene, if available.
- Witness statements, if any.
SIRA will assess this evidence against the Motor Accident Guidelines to determine whether the treatment meets the statutory criteria for funding.
Time Limits and Dispute Procedures
There is no fixed time limit for applying to SIRA for a determination on treatment funding, but delays may affect the outcome. It is best to act promptly after a denial. You must notify the insurer of your intention to dispute the decision in writing. The insurer must then provide a formal response within 28 days. If the dispute remains unresolved, you may submit a formal application to SIRA. SIRA will assess the application and may request further information or arrange a review. Decisions are made by SIRA’s independent assessors and are binding on the insurer.
Hypothetical Example: Treatment Denied After Accident in Greater Sydney
A 38-year-old woman was struck by a car while crossing a footpath in North Ryde, Greater Sydney. She sustained soft tissue injuries to her neck and back. Her treating physiotherapist recommended 12 weeks of manual therapy and exercise rehabilitation. The CTP insurer denied funding on the grounds that the injury was not severe enough to justify ongoing treatment. The claimant obtained a medical report from her specialist confirming a diagnosis of cervical strain with nerve root irritation, and that the treatment was reasonable and necessary. She submitted the report and treatment plan to SIRA, which determined that the treatment met the statutory criteria and ordered the insurer to fund it.
Next Steps and When to Seek Advice
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.