Disputing Treatment Funding Decisions in NSW CTP Claims
If your motor accident insurer has refused to fund a treatment you believe is necessary for recovery, you may request an internal review. This is a formal process within the insurer’s own procedures to reconsider the decision. In New South Wales, the Motor Accident Injuries Act 2017 (MAIA) and the Motor Accident Injuries Regulation 2017 set the framework for how insurers must assess and fund treatment for injury-related care. The process is designed to allow claimants to seek a reconsideration before escalating to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
How Insurers Assess Treatment Funding in NSW
Under the MAIA, insurers are required to fund treatment that is reasonable and necessary for the recovery from injuries sustained in a motor accident. This includes medical treatment, allied health services, and rehabilitation. The insurer must assess whether the treatment is directly related to the accident, medically appropriate, and likely to improve or maintain the claimant’s condition. Funding decisions are based on clinical evidence, including reports from medical practitioners, and must comply with the Motor Accident Guidelines issued by SIRA.
Insurers may refuse funding if they determine the treatment is not medically necessary, not related to the accident, or not cost-effective. A refusal must be in writing and include the reasons for the decision. The insurer must also inform the claimant of their right to request an internal review.
The Internal Review Process: What to Expect
If you disagree with a funding refusal, you can request an internal review from the insurer. This is not a new claim, but a review of the original decision. The insurer must respond to your request within 21 days of receiving it. During this time, they must reassess the medical evidence, including any new reports or assessments you provide.
The review must be conducted by a person who was not involved in the original decision. The insurer must consider all relevant information, including your medical records, treatment plans, and any correspondence with your healthcare providers. If the insurer upholds the original decision, they must provide a written explanation of why the treatment remains unfunded.
Evidence That Supports a Funding Review
To strengthen your case during an internal review, you should provide:
- A detailed report from your treating medical practitioner outlining the injury, treatment plan, and expected outcomes.
- A record of your recovery progress, including notes from physiotherapists, psychologists, or other allied health professionals.
- Photographs of the accident scene, if relevant to establishing the nature of the injury.
- Witness statements, if available, confirming the impact or immediate symptoms.
- Copies of correspondence with the insurer, including the original refusal and any responses.
SIRA’s guidelines state that treatment must be reasonable and necessary. If your treatment is supported by a qualified medical practitioner and aligns with accepted clinical practice, it is more likely to be approved.
Time Limits and Next Steps
There is no statutory time limit for requesting an internal review under the MAIA, but it is advisable to act promptly. Delays may affect the availability of medical records or the ability to obtain updated assessments. If the insurer does not respond within 21 days, or if you are not satisfied with the outcome, you may escalate the matter to the Personal Injury Commission (PIC).
The PIC can review the decision and, if appropriate, order the insurer to fund the treatment. If the PIC upholds the insurer’s decision, you may seek a review by the Supreme Court of NSW, but only on a point of law.
When to Seek Independent Advice
An internal review does not guarantee a change in decision. The insurer may still refuse funding, even if you provide strong medical evidence. In such cases, it is advisable to seek independent legal or medical advice before escalating to the PIC. A solicitor experienced in CTP claims can help you assess whether the insurer’s decision was reasonable and whether you have a strong basis for a formal dispute.
A hypothetical example: A pedestrian was struck by a car in a Sydney car park. They developed chronic back pain and were referred to a physiotherapist. The insurer refused to fund a six-week course of targeted spinal rehabilitation, stating it was not directly linked to the accident. The claimant submitted a report from their specialist confirming a soft-tissue injury to the lumbar spine, with ongoing neurological signs. After an internal review, the insurer approved the treatment.
Final Steps and Contact
Every claim depends on its own facts. The outcome of an internal review depends on the strength of medical evidence, the nature of the injury, and the insurer’s interpretation of what is reasonable and necessary. Time limits and procedural requirements may apply. To request contact about the next step, complete the quick, no obligation enquiry form.