How are treatment costs funded during insurer IME 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).
In New South Wales, Compulsory Third Party (CTP) insurers are legally required to fund independent medical examinations (IMEs) as part of assessing motor accident claims. However, the funding of treatment costs during these exams is governed by specific rules under the Motor Accident Compensation Act 1999 and SIRA guidelines. This article explains how insurers manage funding for treatment during IMEs, what claimants should know, and steps to ensure costs are covered.
NSW CTP Rules on Funding Treatment During IMEs
Under NSW law, CTP insurers must cover the cost of an independent medical examination requested as part of a claim. However, the treatment costs incurred by the claimant during the IME are not automatically funded by the insurer. Instead, these costs fall under the claimant’s broader claim for treatment and care benefits, as outlined in the Motor Accident Injuries Act 2017.
SIRA (State Insurance Regulatory Authority) provides guidance that treatment costs, including medical reports, scans, and specialist consultations, are generally covered under the claimant’s entitlement to treatment and care benefits. This includes costs incurred during an IME, provided the treatment is directly related to the injury sustained in the accident. However, insurers may require claimants to provide evidence that the treatment is necessary and within the scope of the claim.
Practical Steps for Claimants
To ensure treatment costs are covered during an insurer-funded IME, claimants should:
- Keep detailed records: Document all medical treatments, including dates, providers, and costs. This includes records from the IME itself.
- Communicate with the insurer: Inform the insurer of any additional treatment needs identified during the IME. Failure to disclose treatment requirements may result in delays or disputes.
- Seek clarification on funding limits: Understand what costs are covered under the claim and what may require separate approval. For example, some treatments may be limited to 52 weeks after the accident if they are classified as 'threshold injuries' under the Motor Accident Guidelines.
- Request an independent medical opinion: If the IME findings conflict with the claimant’s medical records, they may seek a second opinion from a treating specialist. This can help resolve disputes over the necessity of treatment.
Time Limits and Dispute Resolution
CTP insurers must act within specific timeframes to assess claims, but the exact deadlines depend on the nature of the claim. For example, the 52-week statutory limit for weekly income payments applies only to injuries that meet the 'threshold injury' criteria under the Motor Accident Guidelines. If a claimant’s injuries exceed this threshold, they may be eligible for long-term benefits.
If a claimant disputes the insurer’s funding decision for treatment costs, they can request a review through SIRA or seek legal advice.
Example Scenario
Consider a claimant who sustained a soft-tissue injury in a car accident. After the accident, they undergo an IME funded by the insurer. During the exam, the doctor identifies additional treatment needs, such as physiotherapy. The claimant must ensure that these costs are included in their claim for treatment and care benefits. If the insurer refuses to cover the costs, the claimant should provide evidence of the treatment’s necessity and seek clarification under the Motor Accident Injuries Act 2017.
When to Seek Legal Advice
While many claims are resolved through the CTP scheme, some require legal assistance. A solicitor can help claimants understand their rights under the Motor Accident Compensation Act 1999, challenge decisions about treatment funding, or navigate disputes over the scope of the IME. Legal advice is particularly valuable if the claimant believes the insurer is not acting in good faith or if there are delays in processing the claim.
Next Steps
CTP claims involving independent medical examinations require careful management of treatment costs and documentation. While insurers have a legal duty to fund IMEs, claimants must take proactive steps to ensure their treatment is covered. If you are unsure about how your claim is being handled, seek guidance from a qualified legal professional.
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