If your NSW CTP insurer refuses to fund your treatment costs after a motor accident, you may be able to raise a complaint with the State Insurance Regulatory Authority (SIRA). This article explains the process for lodging a complaint about insurer funding decisions in the Newcastle and Hunter region, the legal boundaries of such complaints, and practical steps to take.
What You Can and Cannot Complain About
SIRA regulates CTP insurers under the Motor Accident Injuries Act 2017. You can complain if your insurer has:
- Refused to fund treatment that is reasonable and necessary
- Delayed payment of treatment costs
- Misinterpreted your claim for treatment funding
However, SIRA cannot intervene in:
- Disputes over the medical necessity of treatment (this is for your treating doctor to assess)
- Decisions about the type or frequency of treatment (subject to your doctor’s clinical opinion)
- Claims for damages beyond the statutory benefits (CTP insurers are not liable for common law damages)
Practical Steps to Take in Newcastle and Hunter
- Gather evidence: Collect all documents related to your treatment costs, including:
- Medical records showing the treatment was recommended
- Itemised bills from healthcare providers
- Correspondence with your insurer about the funding decision
- Evidence of your insurer’s refusal to pay (e.g., written notice or email)
- Review your claim: Check if your insurer has followed the Motor Accident Guidelines for assessing treatment costs. For example, under the guidelines, treatment must be:
- Reasonable and necessary
- Provided by a registered medical practitioner
- Directly related to your injury
- Lodge a complaint with SIRA: Visit SIRA’s complaint page to submit your complaint. You can also contact SIRA directly via phone or email. Note that complaints must be submitted within 28 days of the insurer’s decision, unless there is a valid reason for delay.
What Happens After You Lodge a Complaint
SIRA will review your complaint and may:
- Request additional information from you or your insurer
- Mediate between you and your insurer
- Issue a binding decision if the insurer’s decision is found to be unreasonable
If SIRA finds your insurer has acted unreasonably, it may require the insurer to pay your treatment costs or compensate you for any financial loss caused by the delay.
Example Scenario
Imagine you were in a car accident in Newcastle and your insurer refused to fund your physiotherapy sessions. Your doctor documents that the therapy is necessary to manage your soft tissue injury. You then submit your claim to your insurer, but they reject it, citing a lack of 'clinical evidence'. You can complain to SIRA about this decision, as it relates to the insurer’s interpretation of your medical records.
When to Seek Legal Advice
While SIRA handles complaints about insurer conduct, you may need to consult a solicitor if:
- Your insurer refuses to pay for treatment that your doctor has confirmed is necessary
- You believe your claim for damages has been unfairly denied
- You need assistance with legal procedures such as issuing a claim for common law damages
Next Steps
CTP claims and disputes can depend on the date of your accident, the type of injury, and your insurer’s conduct. To request contact about your circumstances, complete the quick, no obligation enquiry form.