If your NSW CTP insurer has denied or limited funding for treatment costs after a motor accident, you may need to request an internal review. This article explains how insurers handle such disputes, what evidence to prepare, and how SIRA guidelines apply to funding decisions in Ballina. It also covers time limits and when to escalate to the Personal Injury Commission (PIC) or SIRA.
NSW CTP Funding Rules for Treatment Costs
Under the Motor Accident Injuries Act 2017, insurers must fund treatment costs that are reasonably necessary for recovery. This includes medical, physiotherapy, and psychological care. However, funding decisions depend on:
- The type of treatment (e.g., surgery vs. physiotherapy)
- Medical evidence confirming the treatment's necessity
- Whether the treatment aligns with SIRA's clinical guidelines
Insurers may deny funding if they believe the treatment is not 'reasonably necessary' or exceeds the 'threshold injury' definition. For example, if a claimant requires ongoing physiotherapy for a soft tissue injury, the insurer must justify why it's not funded.
Practical Steps for Challenging Funding Decisions
If your insurer denies treatment funding, follow these steps:
- Request an internal review: Write to the insurer's claims manager, citing SIRA's guidelines and providing medical evidence. Include:
- Your medical records
- Treatment plans from your doctor
- Itemised invoices
- Evidence of how the treatment addresses your injury
- Escalate to PIC or SIRA: If the internal review is unsatisfactory, you can apply to the Personal Injury Commission (PIC) for a review. SIRA may also review cases where funding disputes involve complex medical or legal issues.
Time Limits and Dispute Options
You must request an internal review within 28 days of receiving the funding decision. If you don't escalate to PIC or SIRA within 60 days of the initial decision, you may lose the right to challenge the funding. Note that disputes over treatment funding are separate from claims for damages under common law.
Example: Funding a Physiotherapy Program
Consider a claimant who sustained a soft tissue injury and requires 12 weeks of physiotherapy. The insurer denies funding, arguing the treatment is 'not reasonably necessary.' The claimant can challenge this by:
- Submitting a doctor's report confirming the physiotherapy is essential for recovery
- Showing that the treatment aligns with SIRA's guidelines for soft tissue injuries
- Demonstrating that alternative treatments (e.g., rest) are insufficient
If the insurer still refuses funding, the claimant can apply to PIC for a review. However, PIC will not revisit medical opinions unless there's new evidence.
When to Seek Legal Advice
Contact a solicitor if:
- The insurer refuses to provide a written explanation for its funding decision
- You receive a notice of 'no further funding' without a clear reason
- You need help preparing a formal review request to PIC or SIRA
Legal professionals can help you understand whether your treatment costs meet the 'reasonably necessary' standard and whether you have a valid claim for further funding.
Next Steps
CTP funding disputes depend on the accident date, injury type, and evidence provided. If you're in Ballina and need help challenging an insurer's decision, complete the quick, no obligation enquiry form to request contact about your circumstances.