If you're disputing funding for treatment costs during a medical assessment under NSW Compulsory Third Party (CTP) claims, understanding the process is critical. SIRA determines funding based on medical evidence and treatment necessity, but disputes often arise when insurers question the cost or relevance of care. This article explains how claimants in Western Sydney can address such conflicts, including steps to challenge decisions and what to expect from insurers.
How SIRA Determines Funding for Treatment Costs
SIRA's guidelines state that treatment costs must be 'reasonably necessary' for your recovery and supported by medical evidence. This includes therapies like physiotherapy, occupational therapy, and specialist consultations. Insurers assess whether the treatment aligns with the injury's severity and the medical assessment report. For example, if a doctor recommends a 12-week course of physiotherapy, SIRA will fund it unless the insurer disputes the necessity.
Steps to Take if Treatment Costs Are Disputed
If your insurer disputes funding, you must provide detailed evidence. This includes:
- Original medical bills with itemised costs
- Doctor's notes confirming treatment necessity
- Copies of the medical assessment report
- Evidence of financial hardship if applicable
Claimants should request a written explanation of the dispute and submit additional evidence within 28 days. SIRA encourages direct communication with insurers to resolve conflicts without escalating to formal review.
How NSW CTP Insurers Handle Funding Disputes
Insurers in Western Sydney typically follow a two-step process:
- Initial Review: They assess whether the treatment meets SIRA's 'reasonably necessary' threshold.
- Dispute Resolution: If unresolved, claimants can request a review by the Personal Injury Commission (PIC). PIC will examine medical records and may consult with independent experts.
Note that insurers cannot refuse funding for treatment that is 'reasonably necessary' even if it differs from the initial assessment. However, challenges are more likely if the treatment is deemed excessive or not aligned with the injury's severity.
Practical Example: Resolving a Funding Dispute
Consider a claimant who underwent 12 weeks of physiotherapy after a soft-tissue injury. The insurer disputes the cost, arguing it's 'not medically necessary.' The claimant must:
- Submit the physiotherapist's notes confirming the treatment plan
- Provide the medical assessment report linking the injury to the therapy
- Demonstrate that alternative treatments were unavailable
If the insurer still rejects funding, the claimant can request a PIC review. While the process can take up to 90 days, early evidence submission improves outcomes.
Time Limits and When to Seek Advice
You have 28 days from receiving a funding decision to request a review. If the insurer refuses to fund treatment that meets SIRA's criteria, you must act within this period. Delays can result in lost funding opportunities, especially for ongoing treatments like hydrotherapy or speech therapy.
Final Steps for Claimants
If your treatment costs are disputed, take these actions:
- Gather all medical evidence and bills
- Submit a written request for review within 28 days
- Seek legal advice if the insurer refuses to fund 'reasonably necessary' care
NSW CTP funding disputes require careful documentation and timely action. While SIRA aims to resolve conflicts through direct communication, complex cases often need independent review. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.