Insurer Internal Review Process for Treatment and Rehabilitation Plans
When a motor accident occurs in New South Wales, the Compulsory Third Party (CTP) insurer is responsible for assessing and approving treatment and rehabilitation plans for injured claimants. If the insurer disputes or delays approval of a recommended treatment plan, the claimant may request an internal review. This process allows the claimant to present additional evidence and seek reconsideration before escalating the matter to the Personal Injury Commission (PIC) or the State Insurance Regulatory Authority (SIRA).
The internal review is not a formal hearing. It is a procedural step within the insurer’s own process to reassess a decision. The insurer must consider new or additional information, including medical reports, treatment progress, and any correspondence from the claimant’s medical practitioner. The review must be completed within a reasonable timeframe, although no fixed deadline is specified in the Motor Accident Injuries Act 2017. In practice, insurers typically aim to respond within 28 days of receiving a formal review request.
How Insurers Evaluate Disputes About Treatment and Rehabilitation
Insurers assess treatment and rehabilitation plans based on the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. The primary consideration is whether the proposed treatment is reasonable, necessary, and directly related to injuries arising from the motor accident.
To assess reasonableness, insurers examine whether the treatment is consistent with accepted medical practices, whether it is likely to improve the claimant’s condition, and whether it is proportionate to the injury. For example, a claimant with a soft tissue injury may be assessed for physiotherapy, pain management, or psychological support. The insurer will review the treatment plan against the Motor Accident Guidelines, which set standards for appropriate care.
Insurers may also consider whether the treatment plan is being delivered by a qualified provider and whether it aligns with the claimant’s recovery progress. If a claimant has not shown improvement after a reasonable period, the insurer may challenge the ongoing need for treatment. Disputes often arise when a medical practitioner recommends ongoing or more intensive rehabilitation than the insurer deems necessary.
Practical Steps and Evidence for Claimants
If your insurer disputes your treatment or rehabilitation plan, you should act promptly to preserve your rights. The following steps are commonly effective:
- Obtain a written statement from your medical practitioner outlining the medical basis for the treatment plan, including the diagnosis, prognosis, and expected outcomes.
- Gather all medical records, including reports from specialists, imaging results, and progress notes.
- Document any correspondence with the insurer, including emails, letters, and call logs.
- Keep records of treatment attendance and any changes in symptoms or function.
- Request a formal internal review in writing, clearly stating the reasons for disputing the insurer’s decision.
In Greater Sydney, claimants often face delays in accessing treatment due to insurer review processes. To help avoid delays, it is advisable to submit the treatment plan and supporting evidence to the insurer as soon as it is approved by your medical practitioner.
Time Limits, Dispute Resolution and When to Seek Advice
There is no statutory time limit for requesting an internal review. However, delays may affect your ability to access timely treatment or claim reimbursement for out-of-pocket expenses. If the insurer does not respond within a reasonable timeframe or refuses to approve a reasonable treatment plan, you may escalate the matter to the Personal Injury Commission (PIC).
The PIC provides a medical dispute resolution pathway for treatment and rehabilitation plans. This process involves an independent medical review, which may result in a recommendation to approve or modify the plan. The PIC’s decision is binding on the insurer, but not on the claimant, who may still choose to pursue a different treatment path.
It is important to understand that an internal review does not guarantee a change in the insurer’s decision. The insurer may still maintain its position after review. If the review is unsuccessful, you may then apply to the PIC for a formal determination. Seeking independent legal advice at this stage can help you understand your rights, prepare a strong case, and ensure that procedural requirements are met.
A claimant in Greater Sydney who sustained a back injury in a car crash in February 2026 was initially denied coverage for a six-month physiotherapy program. The claimant submitted a detailed report from a musculoskeletal specialist, including MRI findings and functional assessments, and requested an internal review. The insurer upheld its decision, but the claimant later successfully challenged the denial through the PIC medical dispute pathway, which found the treatment was reasonable and necessary.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.