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).
Insurers in New South Wales assess psychological treatment plans for CTP claims based on the SIRA guidelines and the Motor Accident Injuries Act 2017. Understanding how these plans are evaluated is critical for claimants in Auburn seeking compensation for mental health injuries. This article explains the legal framework, evidence requirements, and steps to challenge insurer decisions.
Legal Framework for Psychological Treatment Plans
Under the Motor Accident Injuries Act 2017 (MAIA), insurers must consider whether a psychological treatment plan is 'reasonably necessary' to address a claimant's injury. SIRA's guidelines state that treatment must be directly related to the accident and align with standard clinical practices. For example, a plan must specify the type of therapy (e.g., cognitive behavioural therapy), duration, and how it addresses symptoms like anxiety or depression linked to the accident.
Insurers also evaluate whether the treatment plan meets the 'threshold injury' criteria. Under s 3.11 of the MAIA, a threshold injury includes psychological injuries that result in a 'significant limitation' in daily activities. However, weekly benefits and treatment benefits are generally limited after 52 weeks if the injury is classified as a threshold injury (s 4.4).
Practical Steps for Claimants in Auburn
To challenge an insurer's rejection of a psychological treatment plan, claimants should:
- Provide detailed medical records linking the injury to the accident
- Submit a treatment plan from a registered psychologist or psychiatrist
- Include evidence of how the injury impacts daily life (e.g., work absence, relationship strain)
- Request a review of the insurer's decision within 28 days of receiving the response
A hypothetical example: A claimant involved in a car accident in Auburn develops post-traumatic stress disorder (PTSD). Their psychologist provides a treatment plan for 12 sessions of trauma-focused therapy. The insurer rejects the plan, arguing it's 'not reasonably necessary.' The claimant must demonstrate how the therapy directly addresses PTSD symptoms caused by the accident.
Time Limits and Dispute Options
Claimants must notify their insurer of a psychological injury within 52 weeks of the accident (s 3.28 MAIA). If the insurer denies a treatment plan, claimants can:
- Request a written explanation of the decision
- Submit additional evidence to support the claim
- Seek independent medical opinion (IMO) if the insurer refuses to consider new information
Disputes over psychological treatment plans are often resolved through SIRA's dispute resolution process. Claimants should seek legal advice if the insurer's decision appears to disregard SIRA guidelines or the MAIA's statutory obligations.
When to Seek Legal Advice
Insurers may reject treatment plans based on subjective interpretations of 'reasonably necessary.' A solicitor can help claimants:
- Challenge decisions that ignore SIRA's clinical guidelines
- Navigate the 52-week time limit for weekly benefits
- Explore options for extending treatment if the injury meets whole person impairment thresholds
In complex cases, legal representation ensures claimants understand their rights under the MAIA and SIRA's guidelines.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.