Understanding Treatment Cost Funding in MAI Act Transitional Claims
If you were injured in a motor accident in New South Wales before 1 December 2017, and your claim is still active under the transitional provisions of the Motor Accident Injuries Act 2017 (MAIA), you may be entitled to funding for treatment costs under the CTP scheme. This funding is governed by the MAIA and the Motor Accident Injuries Regulation 2017, and applies across all of NSW. The transitional arrangements allow claimants who were injured under the old Motor Accidents Compensation Act 1999 (MACA) framework to access the new benefits and processes under MAIA, including for treatment and care. However, the way treatment costs are funded depends on the nature of your injuries, the date of your accident, and whether you have reached a threshold for damages.
The Legal Framework for Treatment Funding
Under the MAIA, treatment and care benefits are available to cover reasonable and necessary medical, allied health, and rehabilitation services arising from a motor accident. These benefits are not limited to people who have reached a threshold injury. For transitional claims, the funding of treatment costs follows the same principles as for claims made under the current scheme, but with some important distinctions based on the accident date and injury status.
If your accident occurred on or after 1 December 2017, you are subject to the current MAIA framework. If your accident occurred before that date, you may be in a transitional claim, meaning you are governed by a mix of the old MACA rules and the new MAIA rules. The SIRA website confirms that transitional claimants can access treatment and care benefits under the MAIA, provided the treatment is reasonable and necessary and directly related to the accident.
What Treatment Costs Are Covered
Treatment and care benefits under the MAIA cover a range of services, including physiotherapy, psychology, occupational therapy, chiropractic care, and medical assessments. These benefits are not limited to injuries that meet the threshold for damages. However, if your only injuries are threshold injuries (such as soft tissue injuries, whiplash, or minor fractures), and you have not reached a whole person impairment of 10% or more, your entitlement to treatment and care benefits may be limited after 52 weeks from the date of the accident. This is because the MAIA restricts ongoing treatment and care benefits to 52 weeks in cases where only threshold injuries are sustained.
Damages are only available if you have a threshold injury and a whole person impairment of 10% or more, and you have met the 52-week threshold for treatment. For transitional claims, the 52-week limit applies only to claims where the only injuries are threshold injuries. If you have non-threshold injuries, such as a spinal nerve-root injury with neurological signs, or a fracture that healed with permanent impairment, treatment may continue beyond 52 weeks.
Practical Steps and Evidence That Matter
To secure funding for treatment costs under a transitional claim, you should:
- Obtain and keep detailed medical records from your treating practitioner, including diagnosis, treatment plan, and progress notes.
- Provide a written report from your medical practitioner confirming that the treatment is reasonable and necessary for recovery from the accident.
- Submit a completed claim form to your insurer or to SIRA if you are not in a claim with an insurer.
- Preserve any correspondence with your insurer, including letters denying or approving treatment funding.
- Take photographs of your injury, treatment equipment, or any impact on your daily life, if relevant.
SIRA advises that claimants must notify their insurer within 6 months of the accident, or as soon as practicable, to preserve rights under the MAIA. Failure to notify may affect entitlement to treatment and care benefits, particularly in transitional claims where the insurer may rely on procedural time limits.
Time Limits and Dispute Options
There are time limits that apply to transitional claims. While the MAIA allows for claims to be made up to 3 years from the date of the accident, the 6-month notification rule for treatment and care benefits remains in effect. If your insurer denies funding for treatment, you may request a review under the MAIA. If the review is unsatisfactory, you can apply to the NSW Civil and Administrative Tribunal (NCAT) for a determination. SIRA provides a guide on how to make a claim and dispute a decision, which is available on its website.
A common issue in transitional claims is the application of the 52-week limit. If you have not reached a 10% whole person impairment but continue to need treatment, you may need to demonstrate that your injuries are not solely threshold injuries. For example, a spinal nerve-root injury with confirmed neurological signs (such as loss of reflex, sensory change, or muscle weakness) may still qualify as a non-threshold injury under the Motor Accident Guidelines, even if radiculopathy is not present. This distinction is critical for continuing treatment funding.
A Realistic Example
Consider a person injured in a car crash in Sydney on 15 March 2016. They were treated for whiplash and a minor neck fracture. Their treating doctor confirms that the neck fracture has healed, but they continue to experience chronic pain and limited mobility. They have not reached a 10% whole person impairment. Under the transitional rules, treatment and care benefits are generally limited to 52 weeks from the accident date. However, if the medical evidence shows that the neck injury caused a spinal nerve-root injury with neurological signs (e.g., reduced reflex in the right arm), this may allow for continued treatment funding beyond 52 weeks under the MAIA.
When to Seek Advice
Every claim depends on its own facts. The availability of treatment cost funding in a transitional claim depends on the accident date, injury type, medical evidence, and whether the claimant has reached a threshold for damages. The MAIA provides a framework, but the application of its provisions requires careful assessment of medical and factual evidence.
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