Insurer Disputes Over Treatment Funding in NSW CTP Claims
If your insurer has refused or limited funding for treatment following a motor accident in Greater Sydney, you may request an internal review. This process allows you to ask the insurer to reconsider their decision based on medical evidence and the Motor Accident Injuries Act 2017 (MAIA). The insurer must assess whether the treatment is reasonable, necessary, and directly related to injuries from the accident. Decisions on treatment funding are governed by the MAIA and the Motor Accident Injuries Regulation 2017, not by the insurer’s discretion alone.
The Internal Review Process for Treatment Funding
To request an internal review, you must formally notify the insurer in writing within a reasonable time after receiving the decision. The insurer must respond within 21 days of receiving your request. During the review, the insurer will reassess the medical evidence, including reports from your treating medical practitioner, diagnostic imaging, and any assessments of your injury and functional capacity. The insurer must consider whether the treatment is consistent with the Motor Accident Guidelines and whether it is likely to improve your recovery or reduce long-term impairment.
Legal Boundaries on Treatment Funding Decisions
Insurers cannot deny treatment funding based on cost alone or because a treatment is not listed on a standard schedule. Funding must be granted if the treatment is reasonable and necessary for recovery from injuries sustained in the accident. The MAIA requires that treatment and care benefits cover reasonable and necessary medical, allied health, and rehabilitation services. If the insurer refuses funding, they must provide a written explanation that references the medical evidence and legal criteria under the MAIA.
Practical Steps and Evidence That Matter
Gather and preserve the following evidence to support your internal review request:
- A detailed medical report from your treating practitioner outlining the diagnosis, treatment plan, and prognosis.
- Copies of diagnostic test results (e.g., MRI, X-ray) showing injury-related findings.
- A treatment plan from a registered health professional, including expected duration and outcomes.
- Correspondence with the insurer, including any letters denying or limiting funding.
- Records of out-of-pocket expenses incurred due to the funding refusal.
If the treatment is not being provided due to funding refusal, keep records of all attempts to access care and any delays in treatment.
When to Seek Independent Advice
An internal review does not guarantee a change in decision. If the insurer upholds the refusal, you may escalate the matter to the Personal Injury Commission (PIC) for a formal review. The PIC can assess whether the insurer’s decision was reasonable under the MAIA and the Motor Accident Guidelines. You may also seek independent medical assessment if the insurer disputes the need for treatment.
Time Limits and Procedural Requirements
There is no fixed statutory deadline for requesting an internal review, but delays may affect the PIC’s ability to assess the claim. It is best to act promptly. If you are seeking treatment for a condition that has not resolved after 52 weeks and your only injuries are threshold injuries, weekly benefits and treatment funding may be limited under the MAIA. However, if new or ongoing injuries are identified, treatment funding may continue.
Hypothetical Example
A cyclist in Sydney’s Inner West was struck by a car in a car park. The insurer initially approved physiotherapy and medication for neck pain but later refused funding for a specialist spinal assessment, citing a lack of objective findings. The claimant submitted a detailed report from a musculoskeletal physician, including MRI results showing a disc bulge affecting a spinal nerve root. The insurer reviewed the evidence and reinstated funding for the assessment. This example illustrates how medical evidence can change an insurer’s position during an internal review.
Next Steps: What to Do If the Insurer Maintains Its Decision
If the insurer maintains its refusal after the internal review, you may apply to the Personal Injury Commission for a review of the decision. You must submit your application within 12 months of receiving the insurer’s final decision. The PIC will assess whether the insurer’s decision was reasonable and whether the treatment was necessary and directly related to the accident. You may also seek legal advice to understand your rights and options under the MAIA.
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