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 insurer has denied your NSW Compulsory Third Party (CTP) claim related to treatment and rehabilitation planning, you may need to understand your options. This article explains how insurers handle such denials, what evidence is needed to challenge them, and how SIRA oversees disputes in Balmain. It focuses on practical steps for injured individuals seeking to resolve denied claims.
How Insurers Deny CTP Claims for Treatment and Rehabilitation
CTP insurers in NSW may deny claims for treatment or rehabilitation if they believe the injury does not meet the scheme’s criteria. Common reasons include:
- Threshold injury disputes: Insurers may argue your injury does not qualify as a 'threshold injury' under the Motor Accident Injuries Act 2017. This typically requires neurological signs or specific clinical findings, such as radiculopathy (nerve root irritation) confirmed by a medical practitioner.
- Lack of documented treatment plans: Insurers may reject claims if your treatment plan lacks clear evidence of rehabilitation goals, such as physiotherapy, occupational therapy, or medical management. A written plan from your treating doctor is essential.
- Timing of claims: Insurers may deny benefits if they believe your treatment or rehabilitation request is outside the 52-week statutory period for certain injuries. This applies only if your injuries are classified as 'threshold injuries' under the scheme.
Evidence to Challenge an Insurer’s Denial
To dispute a denial, you must provide evidence that:
- Your injury meets the threshold injury definition in the Motor Accident Guidelines. This may include medical reports detailing neurological signs, imaging results, or clinical notes.
- Your treatment and rehabilitation plan is documented in writing by a registered medical practitioner. This could include a letter outlining your treatment goals, expected duration, and how it addresses your injury.
- You have followed the insurer’s procedures, such as submitting claims within the required timeframe and providing all requested documentation.
If your insurer disputes the necessity of your treatment, you may need an independent medical opinion to support your case. SIRA provides guidelines on what constitutes valid evidence for treatment claims.
SIRA’s Role in Disputing Denied Claims
SIRA oversees the CTP scheme and handles disputes over denied claims. If your insurer denies your treatment or rehabilitation benefits, you can:
- Submit a written objection to the insurer, clearly stating why you believe the denial is incorrect. Include all supporting evidence.
- Request a review by SIRA if the insurer does not resolve the dispute. SIRA may refer your case to a dispute resolution process or a formal review.
- Seek independent medical advice if the insurer disputes the link between your injury and treatment needs. A specialist report may be required to challenge the denial.
SIRA’s dispute process is designed to ensure claims are assessed fairly, but it is important to act promptly. Delays in submitting evidence or objections may reduce your chances of a successful outcome.
Practical Example: A Denied Rehabilitation Claim in Balmain
Consider a scenario where a pedestrian in Balmain is denied CTP benefits for physiotherapy after a motor vehicle accident. The insurer argues the injury does not meet the threshold injury criteria. The injured person provides:
- A medical report confirming radiculopathy (a neurological sign) from a specialist.
- A written treatment plan outlining the need for physiotherapy to address mobility issues.
- Evidence of timely claim submission.
With this evidence, the insurer may reconsider the claim, as the injury meets the threshold criteria under the Motor Accident Guidelines.
Next Steps and When to Seek Advice
If your insurer denies your CTP claim related to treatment or rehabilitation, take the following steps:
- Gather all medical records, treatment plans, and correspondence with the insurer.
- Submit a formal objection within the insurer’s required timeframe.
- Contact SIRA if the dispute is unresolved.
- Seek legal advice if you believe the denial is unfair or if you need assistance with the dispute process.
Time limits and procedural requirements may apply, so acting quickly is essential. Every claim depends on its own facts, and the outcome will depend on the evidence and applicable law.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.