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).
Under the Motor Accident Injuries Act 2017 (MAI Act), treatment and rehabilitation planning for CTP claims in New South Wales is governed by statutory benefits and SIRA guidelines. This article explains how injured road users can understand their rights to treatment planning, rehabilitation support, and how insurers assess medical costs under the MAI Act.
Legal Framework for Treatment Planning
The MAI Act 2017 outlines statutory benefits for injuries caused by motor vehicles. Section 3.11 of the Act specifies that treatment and care benefits are available for injuries requiring medical attention, including rehabilitation. These benefits cover costs like physiotherapy, occupational therapy, and medical equipment. Importantly, the Act does not require proof of fault to access these benefits, as CTP claims are based on the accident’s occurrence, not who was at fault.
SIRA (State Insurance Regulatory Authority) provides authoritative guidance on treatment planning. Their guidelines emphasize that rehabilitation must be clinically justified and aligned with the injured person’s recovery goals. For example, a treatment plan for a soft-tissue injury (threshold injury) must include evidence of neurological signs or spinal nerve-root damage, as defined in the Motor Accident Guidelines. This ensures insurers evaluate claims based on medical necessity, not speculative recovery timelines.
Practical Steps for Rehabilitation Planning
Injured individuals should document their treatment plan by:
- Collecting medical records from doctors, physiotherapists, and specialists
- Keeping a log of rehabilitation activities and progress
- Obtaining a formal treatment plan from a medical practitioner
- Submitting a completed 'Rehabilitation Plan Form' to the insurer
Insurers must assess whether treatment is 'reasonably necessary' under the MAI Act. For instance, if a person requires 12 weeks of physiotherapy for a knee injury, the insurer must approve the plan as part of the 52-week statutory benefit period. After 52 weeks, weekly benefits stop unless the injury is not a 'threshold injury' (as defined in the guidelines).
Time Limits and Dispute Resolution
The MAI Act sets strict time limits for CTP claims. Injured persons must notify their insurer within 52 weeks of the accident, though this period may extend if the injury is not immediately apparent. For example, a person injured in a car accident but diagnosed with a soft-tissue injury three months later may still qualify for benefits if they notify the insurer within the 52-week window.
Disputes over treatment costs must be resolved through SIRA’s dispute resolution process. If an insurer refuses to approve a rehabilitation plan, the injured person can request a review by SIRA. This process ensures claims are evaluated based on clinical evidence, not cost-cutting measures.
When to Seek Legal Advice
While the MAI Act provides a clear framework, injured persons should seek legal advice if:
- Their treatment plan is rejected without explanation
- They face pressure to settle for less than the statutory benefits
- They need help navigating SIRA’s dispute resolution process
Legal professionals can help injured road users understand their rights to rehabilitation support and ensure insurers comply with the MAI Act. This is particularly important for complex cases involving long-term recovery or multiple injuries.
Example: Rehabilitation Planning for a Threshold Injury
Consider a cyclist injured in a collision with a car. The cyclist’s doctor recommends 12 weeks of physiotherapy to address a soft-tissue injury. Under the MAI Act, the insurer must approve this treatment as part of the 52-week statutory benefit period. If the insurer denies the claim, the cyclist can request a review by SIRA, citing the medical practitioner’s assessment as evidence of clinical necessity.
Next Steps
Understanding the MAI Act’s requirements for treatment planning is essential for injured road users. While the statutory framework provides clear guidelines, individual circumstances may require legal assistance to ensure fair compensation. For personalized advice, complete the quick, no obligation enquiry form to request contact about your circumstances.