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 disputing funding for treatment costs in a NSW CTP claim, understanding how SIRA resolves these disputes is critical. Under the Motor Accident Injuries Act 2017, SIRA determines what treatment is funded based on medical evidence and guidelines. This article explains how disputes are resolved, what evidence matters, and when to seek legal advice in Ashfield.
How SIRA Resolves Funding Disputes
SIRA assesses whether treatment costs are funded by evaluating medical reports, clinical guidelines, and the nature of the injury. For example, if a doctor recommends a scan but SIRA disputes its necessity, they will review the medical records to confirm if the treatment aligns with the injury's severity. The Motor Accident Guidelines outline thresholds for funding, such as requiring a 'threshold injury' for certain treatments. If a claimant disagrees with SIRA's decision, they can request a review or challenge the assessment through the Personal Injury Commission (PIC).
Practical Steps for Claimants
When facing a funding dispute, gather all relevant evidence: medical records, treatment invoices, and SIRA correspondence. Document the timeline of your treatment and any communication with SIRA. For instance, if a physiotherapy session was denied funding, ensure you have a dated record of the session and a copy of SIRA's refusal letter. SIRA may also request additional medical opinions to reassess the claim.
Time Limits and When to Seek Advice
You have 52 weeks from the accident date to claim certain benefits under the Motor Accident Injuries Act 2017. However, disputes over treatment funding can extend beyond this period if they involve complex medical assessments. If SIRA refuses to fund essential treatment, seek legal advice promptly. A solicitor can help challenge SIRA's decision or negotiate a revised funding plan.
Example of a Funding Dispute
Consider a claimant who sustained a soft-tissue injury and sought physiotherapy. SIRA disputes the cost, arguing the treatment is not 'reasonably necessary.' The claimant must provide evidence that the physiotherapy was recommended by a medical practitioner and directly related to the injury. If SIRA's assessment is based on outdated guidelines, a legal challenge may be warranted.
Next Steps
CTP funding disputes depend on the accident date, injury type, and evidence provided. If you're unsure whether your treatment costs will be funded, complete the quick, no obligation enquiry form to discuss your options.