Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
If you're in Armidale or another rural NSW area and disagree with how PIC funding is assessed for your treatment costs during a medical evaluation for a CTP claim, you're not alone. This article explains how SIRA determines funding, what steps you can take to challenge a disputed decision, and how rural claimants can navigate the process.
How SIRA Determines Funding for Treatment Costs
- SIRA assesses funding based on the
- Motor Accident Guidelines* and the
- Motor Accident Injuries Act 2017*. During a medical assessment, a healthcare professional evaluates your injuries to determine if they meet the 'threshold injury' criteria. If your injuries qualify, PIC covers treatment costs like physiotherapy, scans, and specialist consultations. However, if the assessment disputes the necessity or cost of treatment, funding may be limited or denied.
Key factors include:
- The type and severity of your injury
- Medical evidence supporting treatment
- Whether the treatment aligns with standard care protocols
- The date of the accident and applicable funding rules
Practical Steps to Challenge a Funding Dispute
If you disagree with the PIC funding decision during a medical assessment, follow these steps:
- Request a detailed explanation of why the funding was denied. SIRA must provide written reasons for its decision.
- Gather medical evidence. Obtain copies of all treatment records, doctor notes, and invoices. Ensure the evidence clearly links your injuries to the accident.
- Seek a second opinion. A specialist report from a different medical professional may help challenge the initial assessment.
- Submit a formal objection through the Personal Injury Commission (PIC). You can request a review of the medical assessment by an independent expert.
Time Limits and Dispute Options
You have 52 weeks from the accident date to claim treatment costs under the PIC scheme. If your injury is classified as a 'threshold injury, ' funding is generally limited to 52 weeks unless you have a 'whole person impairment' of 10% or more. Disputes must be resolved within this timeframe.
If the PIC denies your claim, you can:
- Request a review by the PIC's internal team
- Appeal to the NSW Civil and Administrative Tribunal (NCAT)
- Seek legal advice to explore further options
Rural Considerations for Armidale Claimants
Rural areas like Armidale may face challenges accessing specialist medical opinions or legal support. Ensure you:
- Work with a local solicitor experienced in CTP claims
- Use SIRA's online tools to submit documents
- Consider telehealth consultations for medical assessments
When to Seek Advice
If you're unsure whether your treatment costs qualify for funding, or if the PIC's decision seems unfair, contact a solicitor specialising in NSW CTP claims. They can help you:
- Navigate the medical assessment process
- Challenge funding decisions with evidence
- Understand your rights under the Motor Accident Injuries Act 2017
Final Steps
CTP funding disputes depend on the date of your accident, the nature of your injuries, and the evidence you provide. If you're in Armidale or another rural area, seeking professional guidance ensures your claim is handled correctly. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.