Insurer-Ordered Medical Examinations and Treatment Funding in NSW CTP Claims
If you have been involved in a motor accident in New South Wales and your CTP insurer has requested an independent medical examination (IME), you may be concerned about who pays for any treatment that arises during or as a result of that examination. Under the Motor Accident Injuries Act 2017 (NSW), treatment costs related to your injury are generally funded by the CTP insurer if they are necessary and reasonable. This includes treatment that may be recommended following an IME, provided it is directly linked to injuries sustained in the accident.
The insurer’s obligation to fund treatment does not end because the examination was requested by them. If a medical practitioner advises that treatment is required following the IME, and that treatment is clinically appropriate and proportionate, the insurer must fund it under the statutory framework. This applies whether you are in Greater Sydney or elsewhere in NSW.
Legal Framework for Treatment Funding in CTP Claims
The Motor Accident Injuries Act 2017 (MAIA) governs all CTP claims in NSW. Under this legislation, CTP insurers are required to provide treatment and care benefits for injuries resulting from a motor accident. These benefits cover a range of services including medical treatment, rehabilitation, and allied health services.
An IME is a medical assessment conducted by a specialist doctor, often at the insurer’s request, to assess the nature and extent of your injuries. The MAIA does not allow insurers to refuse funding for treatment simply because the assessment was initiated by them. If the IME results in a diagnosis or recommendation that leads to a treatment plan, the insurer must fund that treatment under the same terms as any other claim-related care.
The insurer’s responsibility to fund treatment is not limited by the timing of the IME. If treatment is recommended immediately after the exam, or if it is part of a longer-term management plan, it remains eligible for funding as long as it is reasonable and necessary.
Practical Steps and Evidence to Support Treatment Funding
To ensure your treatment costs are covered during or after an insurer-ordered IME, you should:
- Obtain a written report from the IME specialist outlining the findings, diagnosis, and any treatment recommendations.
- Request a treatment plan from your medical practitioner that clearly links the proposed treatment to the injuries identified in the IME.
- Keep all records of treatment, including invoices, prescriptions, and appointment confirmations.
- Provide copies of the IME report and treatment plan to your insurer as soon as possible.
- Maintain a log of all communications with the insurer regarding treatment funding.
If the insurer refuses to fund a treatment recommended after the IME, you should request a written explanation. You may then seek a review through the insurer’s internal dispute resolution process, or contact the State Insurance Regulatory Authority (SIRA) for assistance.
Time Limits and Dispute Resolution
There is no specific time limit within the MAIA for requesting funding for treatment that arises after an IME. However, it is best to notify your insurer as soon as you receive a treatment recommendation. Delays in notification may affect the insurer’s ability to assess and approve the treatment, particularly if it involves specialist services or long-term care.
If your insurer refuses to fund a treatment that you believe is necessary and reasonable, you may dispute the decision. The insurer must provide a written response to your dispute. If the dispute remains unresolved, you can apply to SIRA for a review. SIRA has the authority to determine whether a treatment is eligible for funding under the MAIA.
A common example: A pedestrian in Sydney was involved in a motor accident and later underwent an IME arranged by their CTP insurer. The IME report identified a spinal nerve-root injury with neurological signs, including reduced reflexes and sensory changes. The specialist recommended a course of physiotherapy and nerve block injections. The insurer initially declined to fund the injections, citing cost. After the claimant submitted the IME report and a treatment plan from their specialist, the insurer agreed to fund the treatment as it was clinically necessary and proportionate.
When to Seek Independent Advice
While the MAIA provides a clear framework for treatment funding, individual circumstances can vary. If you are uncertain about whether a treatment should be funded, or if your insurer has refused to cover a recommended treatment, it is advisable to seek independent legal or medical advice.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.