Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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).
NSW CTP insurers evaluate psychological treatment plans based on clinical relevance, documentation, and alignment with the injury's nature. Understanding this process helps claimants challenge or support insurer decisions. This guide explains the legal framework, practical steps, and key considerations for injured road users.
Legal Framework for Psychological Treatment Plans
Under the Motor Accident Injuries Act 2017, NSW CTP insurers must assess treatment plans to determine their relevance to the injury. The SIRA guidelines (SIRA, What you can claim) clarify that psychological treatment must be directly related to the motor accident injury. For example, a plan addressing anxiety caused by a recent collision is eligible, while a plan for pre-existing mental health issues may not be.
Insurers also consider whether the treatment plan meets the 'threshold injury' criteria. Under the Motor Accident Injuries Act 2017 s 4.4, injuries must result in a 'loss of function' or 'pain and suffering' to qualify. Psychological treatment plans must demonstrate how the injury impacts daily life, such as sleep disturbances, concentration, or emotional distress.
Factors Insurers Consider
- Clinical Relevance: Insurers review medical records to ensure the treatment plan addresses the injury caused by the accident. For instance, a plan for 'post-traumatic stress disorder' must link the condition to the motor accident.
- Documentation Quality: SIRA (SIRA, Making a motor accident claim) requires detailed records, including therapist notes, diagnosis codes, and treatment goals. A vague plan without specific objectives may be rejected.
- Alignment with SIRA Guidelines: Insurers check if the treatment plan follows SIRA's advice on psychological care. For example, a plan involving cognitive behavioural therapy (CBT) is more likely to be approved than one using unproven alternative methods.
- Evidence of Impairment: The plan must show how the injury affects the claimant's ability to work, study, or perform daily tasks. A therapist's report detailing reduced productivity due to anxiety strengthens the case.
Steps for Claimants Disagreeing with Decisions
If an insurer denies or limits a psychological treatment plan, claimants should:
- Request a written explanation of the decision, referencing SIRA's criteria.
- Submit additional evidence, such as updated medical records or a second opinion from a registered psychologist.
- Appeal through SIRA's dispute process, which allows for a review by an independent assessor.
Time Limits and Practical Considerations
CTP claims must be submitted within 52 weeks of the accident, unless an extension applies. Psychological treatment plans must be submitted within this timeframe to be considered. Delays may result in insurers refusing to cover treatment costs.
Claimants should also ensure their treatment plans are dated and signed by a qualified professional. A plan dated after the 52-week deadline may be excluded from benefits, even if the injury persists.
When to Seek Legal Advice
Complex cases, such as disputes over the validity of a treatment plan or claims involving multiple injuries, may require legal assistance. A solicitor can help claimants:
- Navigate SIRA's application process.
- Challenge decisions based on incomplete or incorrect information.
- Understand how to request a review of a denied claim.
Example Scenario
A cyclist injured in a collision submits a treatment plan for 'depression' and 'sleep disturbances' caused by the accident. The insurer denies the plan, arguing the injuries are 'pre-existing.' The claimant must prove the injuries are directly linked to the accident, such as through a therapist's report detailing trauma from the incident.
Next Steps
CTP entitlements depend on the accident date, injury type, and claim history. To request contact about your circumstances, complete the quick, no obligation enquiry form.