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 Accidents Compensation Act 1999 (MACA), NSW Compulsory Third Party (CTP) insurers fund medical treatment costs for accident victims. This system, which applies to claims arising before 1 December 2017, ensures injured parties receive coverage for essential healthcare expenses. The following explains how treatment costs are funded, what expenses are covered, and the role of the State Insurance Regulatory Authority (SIRA) in managing claims.
How CTP Funding Works Under the 1999 Act
CTP insurers under the MACA are legally required to cover medical treatment costs incurred as a result of a motor vehicle accident. This includes diagnostic tests, specialist consultations, therapy sessions, and other treatments necessary for recovery. The funding applies to both immediate and long-term care, provided the treatment is directly related to the accident.
Insurers must approve treatment plans before they are provided, and claimants must submit medical records to substantiate expenses. SIRA oversees the claims process, ensuring compliance with statutory obligations. For example, if a claimant requires physiotherapy after a car accident, the insurer must cover the cost of sessions deemed medically necessary.
What Medical Costs Are Covered?
Under the MACA, eligible treatment costs include:
- Emergency care and hospital treatment
- Specialist medical opinions and diagnostic imaging
- Rehabilitation services such as physiotherapy
- Medications prescribed for accident-related injuries
- Transportation to and from medical appointments
Costs not directly related to the accident, such as elective procedures or non-essential treatments, are generally not covered. Claimants must provide evidence that the treatment was necessary for recovery.
SIRA's Role in Assessing Treatment Claims
SIRA acts as the independent authority for resolving disputes over treatment funding. When a claimant and insurer disagree on the necessity or cost of treatment, SIRA evaluates the medical evidence and makes a binding decision. This process ensures that claimants receive appropriate care while preventing unnecessary expenses.
For instance, if a claimant seeks a second opinion from a specialist, SIRA will assess whether the opinion is relevant to the injury and whether the cost is reasonable. This role is critical in balancing the interests of claimants and insurers.
Practical Steps for Claimants
To ensure treatment costs are funded under the MACA:
- Obtain medical records documenting the injury and recommended treatment
- Submit treatment plans to the insurer for pre-approval
- Keep receipts and invoices for all medical expenses
- Notify SIRA if the insurer refuses to cover a necessary treatment
Claimants should also be aware of time limits. Under the MACA, weekly benefits and treatment coverage are generally limited to 52 weeks unless the injury meets the threshold injury criteria outlined in the Motor Accident Guidelines.
Disputes and When to Seek Advice
If an insurer denies coverage for a treatment deemed necessary by a doctor, claimants can request a review by SIRA. Disputes may also arise over the extent of coverage or the cost of specific treatments. In such cases, legal advice may be necessary to challenge the insurer's decision.
For example, treatment costs for pre-existing conditions or injuries unrelated to the accident are typically excluded. Claimants should seek guidance to understand what is covered under their specific circumstances.
Next Steps for Claimants
CTP funding under the MACA depends on the date of the accident, the nature of the injury, and the evidence provided. While this article explains the general framework, each claim is unique. To request contact about your circumstances, complete the quick, no obligation enquiry form.