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 you're seeking physiotherapy treatment approval for your NSW Compulsory Third Party (CTP) motor accident claim, understanding what evidence insurers require is critical. Under the Motor Accident Injuries Act 2017, insurers must approve treatment plans that align with the injury’s severity and medical necessity. This article explains the evidence you need to support your claim, records to retain, and how to navigate disputes.
What Evidence Supports Physiotherapy Approval in CTP Claims?
Insurers rely on clinical documentation to determine if physiotherapy is medically necessary. Key evidence includes:
- Medical reports from a registered medical practitioner confirming the injury’s nature, severity, and treatment needs.
- Treatment plans outlining the type, frequency, and expected outcomes of physiotherapy.
- Insurer correspondence showing your attempts to secure approval, including dates and responses.
- Clinical records like progress notes, imaging results, and specialist opinions that justify the treatment.
SIRA’s guidelines stress that treatment must be “reasonably necessary” and “directly related to the injury.” For example, if your physiotherapist recommends exercises for a soft-tissue injury, you must show how these align with the injury’s diagnosis.
Records to Keep for Physiotherapy Approval
Maintaining detailed records ensures your claim remains on track. Retain:
- Original medical records (e.g., MRI reports, GP notes) showing the injury’s impact on your mobility or function.
- Physiotherapy invoices with dates, session descriptions, and the therapist’s contact details.
- Treatment plan approvals from your insurer, even if they’re partial or conditional.
- Witness statements or accident reports that contextualize the injury’s cause.
- Correspondence with your insurer, including emails or letters requesting approval.
If your treatment is denied, keep copies of all communication to challenge the decision later.
SIRA’s Role in Physiotherapy Approval
SIRA’s What You Can Claim page clarifies that physiotherapy is available for injuries meeting the “threshold injury” criteria under the Motor Accident Guidelines. This includes soft-tissue injuries like whiplash or muscle strains, provided they meet the spinal nerve-root definition in the guidelines.
A hypothetical example: Sarah sustained a soft-tissue injury in a Greater Sydney car accident. Her physiotherapist recommended 12 sessions to improve mobility. To secure approval, Sarah’s GP documented the injury’s impact on her daily activities, and the physiotherapy plan was reviewed by a physiotherapist. This alignment with clinical guidelines helped her insurer approve the treatment.
Time Limits and Dispute Resolution
You have 52 weeks from the accident date to claim weekly benefits for threshold injuries. After this period, insurers may stop paying benefits unless you have a “whole person impairment” (WPI) rating of 10% or more. If your physiotherapy is denied, you can:
- Request a review of the insurer’s decision in writing.
- Seek independent medical advice to challenge the insurer’s assessment.
- Appeal to the NSW Civil and Administrative Tribunal (NCAT) if disputes escalate.
When to Seek Legal Advice
If your insurer refuses to approve your physiotherapy or disputes the injury’s severity, consult a solicitor. They can help you:
- Navigate SIRA’s complex guidelines.
- Challenge decisions based on clinical evidence.
- File a claim for damages if your injury exceeds threshold criteria.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.