If your CTP insurer has denied funding for treatment costs after a motor accident in Western Sydney, you may need to challenge their decision. Under NSW law, insurers must cover eligible medical expenses as part of a CTP claim. This article explains how to dispute a denial, what evidence matters and when to seek independent advice.
What happens when an insurer denies a CTP claim for treatment costs?
CTP insurers are legally required to fund treatment costs if the injury meets the scheme's criteria. Denials often occur when insurers dispute the injury's eligibility, the treatment's necessity or the claimant's entitlement. For example, an insurer might refuse to cover physiotherapy if they claim it's not 'reasonably necessary' under the Motor Accident Guidelines.
Under the Motor Accident Injuries Act 2017, claimants can challenge such denials by submitting additional medical evidence or disputing the insurer's interpretation of the guidelines. SIRA's role is to mediate disputes and ensure claims align with the scheme's rules.
Practical steps to challenge denied treatment funding
- Review the denial letter: Insurers must provide reasons for refusing coverage. Common grounds include disputes over injury severity, treatment type or claimant's entitlement. For instance, an insurer might argue a soft tissue injury (threshold injury) doesn't qualify for ongoing treatment benefits.
- Gather medical evidence: Your treating doctor must confirm the treatment's necessity. Keep records of all medical reports, invoices and correspondence with healthcare providers. If the insurer disputes a specific treatment, a second opinion from a specialist may be needed.
- Submit a formal dispute: Use SIRA's online portal or contact them directly to challenge the denial. You'll need to explain why the treatment should be funded, referencing the Motor Accident Guidelines. For example, if the insurer refuses a cortisone injection, you might argue it's a clinically indicated treatment for your injury.
- Seek independent advice: If the insurer refuses to budge, consult a legal professional. SIRA's dispute resolution process can take up to 90 days, and claimants may need to escalate to the NSW Civil and Administrative Tribunal (NCAT) if unresolved.
Time limits and when to act
CTP claims must be submitted within 90 days of the accident, but disputes about treatment funding can extend beyond this. However, insurers can refuse to pay from the 52-week mark if the injury is classified as a 'threshold injury' under the scheme. If your claim is denied after this period, you may need to re-evaluate your options.
Example: Disputing a denied cortisone injection
A claimant in Western Sydney was denied funding for a cortisone injection for a soft tissue injury. Their doctor provided evidence showing the injection was clinically necessary to manage pain and improve mobility. By submitting this evidence to SIRA and explaining how the treatment aligned with the Motor Accident Guidelines, the claimant successfully secured funding.
When to seek legal advice
If your insurer refuses to fund essential treatment, or if you're unsure whether your injury qualifies, it's wise to consult a legal professional. SIRA's dispute process can be complex, and claimants may need assistance navigating the rules around treatment eligibility and time limits.
Next steps
CTP claims involving treatment funding can be complex, especially when insurers deny coverage. Understanding your rights under the Motor Accident Injuries Act 2017 and the practical steps to challenge a denial is crucial. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.