Understanding Insurer Disputes Over Treatment Funding in NSW
If your insurer in Bankstown has denied or limited funding for medical treatment following a motor accident, you have the right to request an internal review. This process allows you to ask the insurer to reconsider its decision based on medical evidence and the Motor Accident Injuries Act 2017. Insurers must follow SIRA’s guidelines when assessing treatment claims, including whether the treatment is reasonable, necessary and directly related to injuries from the accident. This applies regardless of whether the accident occurred on a public road, in a car park, or on private property, as long as the motor vehicle was being used in a way that falls under the CTP scheme.
The Legal Framework for Treatment Funding in NSW
Under the Motor Accident Injuries Act 2017, insurers are required to fund treatment and care benefits for injuries sustained in a motor accident. These benefits cover medical treatment, rehabilitation, and support services. The insurer must assess whether the treatment is reasonable, necessary, and directly related to the accident. SIRA’s guidelines state that treatment must be clinically appropriate and not excessive. If the insurer refuses to fund treatment, they must provide a written explanation of the basis for the decision, including reference to the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017.
Steps to Request an Internal Review
To challenge a funding decision, you must formally request an internal review from your insurer. This should be done in writing and include:
- A copy of the treatment plan or recommendation from your medical practitioner
- A summary of your injury and how it relates to the accident
- Any supporting evidence such as medical reports, diagnostic imaging, or correspondence with healthcare providers
The insurer must respond within 28 days of receiving your request. During this time, you may be asked to provide further information. It is important to keep copies of all correspondence and to record the date of submission. If the insurer upholds its original decision, you may then apply to the Personal Injury Commission (PIC) for a review.
What to Include in Your Internal Review Submission
To strengthen your case, ensure your submission includes:
- A detailed treatment plan from your medical practitioner, clearly linking the treatment to your accident-related injuries
- Evidence of medical necessity, such as a clinical assessment or diagnostic report
- A record of how the treatment has impacted your recovery or daily function
SIRA’s guidelines state that treatment must be both reasonable and necessary. If your treatment is recommended by a qualified medical practitioner and is part of a documented recovery plan, it is more likely to be approved. For example, if you have sustained a soft tissue injury to the neck and your physiotherapist recommends six weeks of targeted exercises to restore function, this would be considered reasonable and necessary under the scheme.
When to Escalate to the Personal Injury Commission
If the insurer’s internal review does not change its decision, you may apply to the Personal Injury Commission (PIC) for a review. The PIC has jurisdiction to assess whether the insurer’s decision was correct under the Motor Accident Injuries Act 2017. You must apply within 60 days of receiving the insurer’s final response. The PIC may request additional medical evidence, including a second opinion, to determine whether the treatment should be funded.
Common Reasons for Funding Disputes
Insurers often dispute treatment funding on grounds such as:
- The treatment is not directly related to the accident
- The treatment is considered excessive or not clinically necessary
- The treatment was not recommended by a qualified medical practitioner
These grounds must be supported by medical evidence. If the insurer relies on a medical report that contradicts your treating practitioner’s assessment, you may request a review by an independent medical expert through the PIC.
Practical Evidence That Matters
The following evidence is most likely to support a successful internal review:
- A written treatment plan from your treating medical practitioner
- Diagnostic imaging (e.g. MRI, X-ray) showing injury consistent with the treatment
- Progress notes from your treatment provider showing ongoing symptoms
- A record of how the treatment has affected your ability to work, drive, or perform daily activities
Keep all original documents and copies. Do not alter or destroy any records related to your claim.
Time Limits and Procedural Requirements
There is no automatic right to treatment funding. The insurer must assess each claim on its merits. However, delays in processing claims may affect your recovery. If you have not received a response to your internal review request within 28 days, you may contact SIRA for assistance. The PIC has a 60-day time limit for applications after a final insurer decision. Missing this deadline may prevent you from seeking a formal review.
Hypothetical Example
A 42-year-old resident of Bankstown was involved in a rear-end collision in a car park in August 2024. She developed persistent neck pain and was referred to a physiotherapist for targeted rehabilitation. Her insurer initially refused to fund the treatment, stating it was not directly related to the accident. She submitted an internal review request with a treatment plan, MRI results showing cervical disc injury, and progress notes. The insurer reviewed the evidence and approved funding after 24 days. This example illustrates how a formal internal review, supported by medical evidence, can result in a favourable outcome.
Seeking Independent Advice
While internal reviews are a standard step, they do not guarantee a change in decision. The insurer may still determine that the treatment is not reasonable or necessary under the Act. If you are unsure about your rights, or if the insurer has not responded within 28 days, it is advisable to seek independent advice. SIRA provides information on the claim process, but it does not represent individuals in disputes.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.