Why NSW CTP Insurers Deny Treatment and Rehabilitation Claims
New South Wales insurers often deny claims for treatment and rehabilitation costs by arguing the injuries do not meet the scheme’s criteria. Common reasons include claims that the injuries are not 'threshold injuries', the treatment plan lacks medical necessity, or the rehabilitation costs exceed the scheme’s limits. Under the Motor Accident Injuries Act 2017, insurers must assess claims based on medical evidence and SIRA’s guidelines, but they may challenge claims by disputing the validity of the treatment plan or the necessity of rehabilitation.
SIRA’s Guidance on Treatment Planning and Denials
SIRA’s authoritative guidance clarifies that treatment and rehabilitation planning must be based on a 'reasonable and necessary' medical assessment. For example, if a claimant’s treatment plan includes physiotherapy for a soft-tissue injury, the insurer must evaluate whether the treatment aligns with the Motor Accident Guidelines. SIRA states that insurers cannot deny claims solely because the treatment is 'non-surgical' or 'non-traditional', provided the plan is medically justified.
Evidence to Challenge an Insurer’s Denial
To challenge a denial, claimants must provide:
- Medical records showing a diagnosed injury and treatment plan
- Doctor’s notes confirming the necessity of rehabilitation
- SIRA-approved treatment guidelines supporting the plan
- Evidence of financial impact (e.g., lost income from treatment)
Insurers may also dispute claims by arguing the treatment is 'not reasonable' or 'not necessary', but SIRA requires that such decisions be based on clinical evidence, not cost-effectiveness.
Legal Protections for Claimants
Under the Motor Accident Injuries Act 2017, claimants have the right to dispute an insurer’s decision. If an insurer denies a claim, they must provide a written explanation. Claimants can request a review by the NSW Civil and Administrative Tribunal (NCAT) if they disagree with the insurer’s assessment. SIRA also provides a free claims assistance service to help injured people challenge denials.
Example: Denial of Rehabilitation Costs
Consider a claimant who suffered a soft-tissue injury and was prescribed 12 weeks of physiotherapy. The insurer denied the claim, arguing the treatment was 'not essential'. The claimant could challenge this by submitting a medical report from a specialist confirming the physiotherapy was necessary to prevent long-term mobility issues. SIRA’s guidelines support such claims if the treatment aligns with standard medical practice.
Next Steps for Claimants
If an insurer denies a treatment or rehabilitation claim, the first step is to request a written explanation of the denial. Claimants should then gather additional medical evidence or seek a second opinion. In some cases, disputing the denial may require legal assistance, especially if the insurer refuses to review its decision. Always act within the 52-week statutory limit for benefits, as outlined in the Motor Accident Injuries Act 2017.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.