How Insurers Fund Treatment Costs During Independent Medical Examinations in NSW CTP Claims
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).
Under New South Wales Compulsory Third Party (CTP) insurance rules, insurers must cover treatment costs related to injuries sustained in a motor accident. However, when an insurer requests an independent medical examination (IME) to assess a claim, the funding of treatment during the exam is governed by specific legal guidelines. This article explains how insurers fund treatment during IMEs, your rights as a claimant in Bankstown, and steps to challenge improper funding decisions.
NSW CTP Rules on Funding Treatment Costs During IMEs
The Motor Accident Injuries Act 2017 and SIRA guidelines outline that insurers must fund treatment costs necessary to address injuries caused by the accident. This includes medical tests, consultations, and therapies. However, insurers may require pre-approval for certain treatments during an IME. For example, if an IME determines that a claimant needs physiotherapy, the insurer must cover those costs unless the treatment is deemed unnecessary.
SIRA’s What You Can Claim page confirms that treatment and care benefits are available for injuries resulting from a motor accident. This includes costs incurred during an IME, provided the treatment is directly related to the injury. Insurers cannot refuse funding for necessary treatment simply because an IME is being conducted.
Claimants' Rights Regarding Funding During IMEs
As a claimant, you have the right to receive treatment that is medically necessary to address your injury. If an insurer refuses to fund treatment during an IME, you can request a written explanation of their decision. SIRA’s Making a Motor Accident Claim guide outlines that claimants must provide evidence of the treatment’s necessity, such as a doctor’s report or medical records.
For example, if an IME concludes that a shoulder injury requires physiotherapy, the insurer must cover the cost of sessions. If the insurer disputes this, you can challenge their decision by submitting additional medical evidence or seeking an independent review.
Challenging Improper Funding Decisions
If an insurer denies funding for treatment during an IME, you can dispute their decision by:
- Submitting medical records that confirm the treatment’s necessity
- Requesting a second opinion from a treating medical practitioner
- Seeking mediation through SIRA’s dispute resolution process
Under the Motor Accident Injuries Act 2017 s 4.4, insurers must cover treatment costs unless the injury is a ‘threshold injury’ (a minor soft-tissue injury with no significant impairment). If your injury meets the threshold definition, the insurer may limit funding after 52 weeks, but this does not apply to all treatment costs.
Time Limits and When to Seek Advice
Statutory benefits under the CTP scheme are generally limited to 52 weeks for injuries that do not meet the whole person impairment threshold. However, treatment costs for necessary care must be funded regardless of the time frame. If you believe an insurer is improperly restricting funding, act promptly to challenge their decision.
Seeking legal advice is recommended if an insurer refuses to fund treatment or disputes the necessity of care. A solicitor can help you navigate the process and ensure your rights are protected under NSW law.
Next Steps
CTP funding rules can vary depending on the accident date, injury type, and insurer policies. To request contact about your circumstances, complete the quick, no obligation enquiry form.