If your NSW CTP insurer refuses to fund your treatment costs, you may have grounds to complain to SIRA. This article explains the process for disputing funding decisions under the Motor Accident Injuries Act 2017, focusing on treatment cost disputes in Ashfield. SIRA oversees compliance with CTP rules, including funding obligations. Understanding your rights and the legal framework is essential before taking action.
Legal Framework for CTP Funding Disputes
Under the Motor Accident Injuries Act 2017, insurers must fund treatment costs for eligible injuries. Section 4.4 of the Act specifies that weekly benefits and treatment care payments are limited after 52 weeks if only threshold injuries are involved. However, this does not apply if your injury exceeds the threshold. SIRA enforces these rules, ensuring insurers comply with their funding obligations.
The Motor Accident Guidelines define threshold injuries, which include soft tissue injuries meeting specific neurological criteria. If your injury meets these thresholds, your insurer must fund treatment. If your injury exceeds the threshold, you may be eligible for ongoing weekly payments and treatment coverage. SIRA provides resources to help claimants understand their entitlements and challenge funding decisions.
Steps to File a SIRA Complaint About Treatment Funding
To dispute your insurer's refusal to fund treatment costs, follow these steps:
- Gather evidence: Collect medical records, treatment invoices, and any correspondence with your insurer. These documents demonstrate your treatment needs and the insurer's refusal to cover costs.
- Review your claim: Check if your injury meets the threshold injury criteria. If your injury exceeds the threshold, your insurer must fund ongoing treatment. If your injury is a threshold injury, your weekly benefits may be limited after 52 weeks.
- Contact your insurer: Request a written explanation for the refusal to fund treatment. This provides a formal record of your dispute.
- Submit a complaint to SIRA: Use the online complaint form on the SIRA website. Include details of your injury, the insurer's refusal, and any supporting evidence.
SIRA typically responds to complaints within 28 days. If your complaint is rejected, you may need to escalate the matter to the NSW Civil and Administrative Tribunal (NCAT) for further review.
Practical Evidence and Dispute Resolution
When disputing treatment funding, focus on the following evidence:
- Medical reports: These must show your injury meets the threshold injury criteria or exceeds it.
- Treatment invoices: These prove your treatment costs and the insurer's refusal to cover them.
- Insurer correspondence: Any written communication from your insurer confirms the refusal to fund.
- Witness statements: Statements from medical professionals or witnesses can support your claim.
If your insurer disputes your claim, SIRA will review your evidence and determine whether your injury meets the threshold. If your injury exceeds the threshold, your insurer must fund ongoing treatment. If your injury is a threshold injury, your weekly benefits may be limited after 52 weeks.
Time Limits and When to Seek Advice
You have 52 weeks from the date of your accident to claim weekly benefits if your injury is a threshold injury. If your injury exceeds the threshold, you may be eligible for ongoing weekly payments. If your insurer refuses to fund your treatment after this period, you may need to seek legal advice.
If your insurer refuses to fund your treatment, you may need to seek legal advice. A solicitor can help you challenge your insurer's decision and ensure you receive the funding you are entitled to.
Next Steps
If your insurer refuses to fund your treatment costs, you may have grounds to complain to SIRA. By following the steps outlined above, you can dispute your insurer's decision and ensure you receive the funding you are entitled to. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.