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).
If you're disputing funding for treatment costs during a medical assessment under NSW's Compulsory Third Party (CTP) scheme, understanding the process is critical. SIRA (State Insurance Regulatory Authority) oversees funding decisions, and disputes often arise when claimants (PICs) believe their treatment is essential but not approved. This article explains how SIRA determines funding eligibility, steps to resolve disputes, and how the CTP scheme handles conflicts between claimants and insurers.
How SIRA Determines Funding Eligibility
- SIRA evaluates treatment costs based on the
- Motor Accident Injuries Act 2017* and its guidelines. Funding is granted if the treatment is clinically necessary for recovery, as determined by a medical practitioner. For example, if a claimant requires physiotherapy to address a soft-tissue injury, SIRA will assess whether the treatment aligns with the
- Motor Accident Guidelines*.
Key factors include: the type of treatment, its relevance to the injury, and evidence from medical records. SIRA may also consider whether the treatment is standard practice for the injury's severity. If a claimant disagrees with a funding decision, they can request a review through the Personal Injury Commission (PIC) process.
Steps to Resolve Funding Disputes
If your treatment costs are disputed during a medical assessment, take these steps:
- Request a written explanation from SIRA detailing why the treatment was denied.
- Provide additional medical evidence, such as a second opinion or updated treatment plans.
- Submit a formal review request through the PIC process, which allows for an independent assessment.
SIRA must respond to a review request within 28 days, though complex cases may take longer. During this time, claimants should avoid altering treatment plans unless advised by their medical team.
Time Limits and Conflict Resolution
Disputes over funding must typically be resolved within 52 weeks of the accident, as per the CTP scheme's statutory limits. However, this timeframe may extend if the claimant can demonstrate that the treatment was not available or necessary during the initial period.
Conflicts between claimants and insurers often arise when insurers dispute the necessity of treatment. In such cases, the PIC process allows for a formal review, though it does not guarantee a change in funding decisions. Claimants should note that SIRA's final decision is binding unless there is a legal challenge, which is rare and requires strong evidence.
Example: A Balmain Claimant's Experience
Consider a claimant in Balmain who sustained a soft-tissue injury and sought physiotherapy. SIRA initially denied funding, arguing the treatment was not 'clinically necessary.' The claimant submitted a second medical opinion confirming the treatment's relevance, leading to a review. SIRA approved the funding after reassessing the evidence. This example highlights how disputes can be resolved through proper documentation and review requests.
When to Seek Legal Advice
While SIRA provides a structured process for resolving funding disputes, claimants may need legal assistance to navigate complex cases. A solicitor can help challenge SIRA's decision if there is evidence of procedural errors or misinterpretation of medical guidelines. However, legal action is typically a last resort and requires a strong case.
Next Steps
CTP funding disputes can be resolved through SIRA's internal review process, but the outcome depends on the evidence and timing. If you're in Balmain and facing a funding dispute, it's essential to act promptly and gather all relevant medical documentation. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.