How CTP Insurers Deny Claims Related to Treatment and Rehabilitation
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).
Insurers often deny CTP claims by disputing the necessity of treatment or rehabilitation plans, arguing that the proposed care is not 'reasonably necessary' under the Motor Accident Injuries Act 2017. On the Central Coast, this tactic is common when claimants seek ongoing therapy, physiotherapy, or psychological support. Insurers may also challenge the cost of treatment, claim that the injury is not 'threshold' under the Motor Accident Guidelines, or assert that the claimant has not followed a specific care plan.
Your Legal Rights Under NSW CTP Rules
Under the Motor Accident Injuries Act 2017, claimants have the right to:
- Challenge denied claims by providing evidence of medical necessity, such as reports from treating doctors or physiotherapists.
- Request a review of decisions by the claimant’s insurer or the NSW Civil and Administrative Tribunal (NCAT) if the insurer refuses to reconsider.
- Access SIRA guidelines to understand what treatment and rehabilitation options are covered. SIRA’s What you can claim page (https://www.sira.nsw.gov.au/claims/motor-accidents/what-you-can-claim) outlines eligible care, including physiotherapy, occupational therapy, and psychological services.
How to Challenge a Denied CTP Claim on the Central Coast
- Review the denial letter to identify the specific reason for rejection. Common grounds include:
- Disputing the injury’s severity (e.g., claiming it’s not a 'threshold injury').
- Arguing that the treatment plan is not 'reasonably necessary' under the Motor Accident Guidelines.
- Refusing to cover costs of non-urgent or elective treatments.
- Gather supporting evidence:
- Medical records from your GP, physiotherapist, or psychologist.
- A detailed treatment plan from your treating practitioner, including goals and timelines.
- Evidence of how the injury impacts your daily life, such as work absences or reduced mobility.
- Use SIRA’s dispute process:
- If the insurer refuses to resolve the issue, you can apply to NCAT for a review. SIRA provides a template for dispute forms on its
- Making a motor accident claim* page (https://www.sira.nsw.gov.au/claims/motor-accidents/making-a-claim).
- You may also seek assistance from a local legal aid office or a solicitor specialising in CTP claims.
- Consider a hypothetical example:
A Central Coast claimant, injured in a car accident, sought physiotherapy for chronic back pain. The insurer denied the claim, arguing that the treatment was 'elective' and not 'reasonably necessary.' The claimant challenged the denial by providing a doctor’s report confirming the injury’s severity and the necessity of physiotherapy. After a review, the insurer agreed to cover the treatment.
Time Limits and Next Steps
CTP claims must be made within five years of the accident date, but disputes over treatment and rehabilitation can extend beyond this period. If your claim is denied, act quickly: insurers often have strict deadlines for reviewing disputes. Contact SIRA directly for guidance, or seek advice from a local solicitor familiar with Central Coast CTP claims.
When to Seek Legal Advice
If the insurer refuses to reconsider your claim or if you’re unsure how to respond to a denial, consult a solicitor. Legal advice can help you:
- Navigate the SIRA dispute process.
- Challenge decisions based on the Motor Accident Guidelines.
- Understand your rights under the Motor Accident Injuries Act 2017.
Next Steps for Claimants
If your CTP claim has been denied, take these actions:
- Review the denial letter and identify the legal grounds for rejection.
- Gather medical evidence to support your treatment and rehabilitation needs.
- Contact SIRA or a local legal aid organisation for assistance.
- Consider applying to NCAT if the insurer refuses to resolve the dispute.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.