How to Challenge a Denied Physiotherapy Approval in NSW CTP Claims
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 your physiotherapy treatment has been denied under the NSW Compulsory Third Party (CTP) scheme, you have options to dispute the decision. The Central Coast's SIRA (State Insurance Regulatory Authority) manages CTP claims, and claimants must follow specific processes to challenge denied approvals. This article explains the legal rules, dispute resolution pathways, and practical steps to contest a denied physiotherapy claim.
NSW CTP Rules for Physiotherapy Treatment Approval
Under the Motor Accident Injuries Act 2017, claimants are entitled to treatment and care benefits, including physiotherapy, if the treatment is medically necessary. SIRA's guidelines state that insurers must approve treatment plans that align with clinical evidence. However, insurers may deny coverage if they believe the treatment is not 'reasonably necessary' or does not meet the 'threshold injury' criteria.
The key legal test for physiotherapy approval is whether the treatment is 'reasonably necessary' to address the injury. This requires medical evidence, such as a doctor's report, to demonstrate the treatment's relevance. If your claim is denied, the insurer must provide a written explanation of the grounds for refusal.
Dispute Resolution Options on the Central Coast
1. Internal Review by the Insurer
The first step is to request an internal review of the denial. Under SIRA's rules, claimants have 28 days from the date of the denial to ask the insurer to reconsider its decision. This process allows the insurer to reassess the claim based on new evidence or a reassessment of the medical records.
2. Escalating to the Personal Injury Commission (PIC)
If the internal review is unsuccessful, claimants can escalate the dispute to the Personal Injury Commission (PIC), a body that resolves medical disputes under the CTP scheme. The PIC will review the claim based on medical evidence and the insurer's reasoning.
To apply to the PIC, you must submit a written request within 28 days of the insurer's final decision. The PIC will schedule a medical review, which may involve a specialist assessing your treatment plan. Note that the PIC's decision is not guaranteed and depends on the evidence provided.
3. Legal Challenges and External Mediation
In rare cases, claimants may seek legal advice to challenge the insurer's decision through the NSW Civil and Administrative Tribunal (NCAT). However, legal action is typically a last resort and requires proof that the insurer's decision was legally flawed.
Practical Steps and Evidence to Gather
To strengthen your dispute, collect the following evidence:
- Medical records: Include your doctor's notes, imaging reports, and any correspondence with your physiotherapist.
- Treatment plan: Provide a detailed plan outlining the purpose and expected benefits of the physiotherapy.
- Insurer correspondence: Keep copies of all communication with the insurer, including the denial letter.
- Witness statements: If applicable, include statements from healthcare professionals or witnesses supporting your claim.
Time Limits and Key Considerations
The 28-day internal review period is critical. Missing this deadline may prevent you from escalating the dispute. Additionally, the 52-week statutory benefit limit applies only to weekly income payments, not to treatment approvals. If your injury meets the 'threshold injury' criteria, you may still be eligible for treatment benefits beyond 52 weeks.
Example: Contesting a Denied Physiotherapy Claim
Imagine a claimant who suffered a soft-tissue injury in a car accident. Their doctor recommended physiotherapy to prevent long-term complications. The insurer denied the claim, arguing the treatment was 'not reasonably necessary.' The claimant requested an internal review, submitted the doctor's report, and the insurer approved the treatment. This example shows how medical evidence can overturn a denial.
When to Seek Legal Advice
If your dispute involves complex medical issues, such as a dispute over the 'whole person impairment' rating, legal advice may be necessary. A solicitor can help you navigate the PIC process or challenge the insurer's decision through NCAT.
Next Steps
Disputing a denied physiotherapy approval requires a clear understanding of the CTP scheme and the evidence needed to support your claim. If you're on the Central Coast and need assistance, contact a legal professional familiar with SIRA's rules. Every claim depends on its own facts.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.