If your NSW insurer has refused to fund your treatment costs after a motor accident, you may be eligible to dispute their decision through the State Insurance Regulatory Authority (SIRA). This article explains how to file a complaint with SIRA about treatment funding decisions, what evidence is required, and how SIRA evaluates insurer actions under the Motor Accident Injuries Act 2017 (MAIA). Time limits and practical steps are also outlined.
What SIRA Does in Treatment Funding Disputes
SIRA oversees the administration of NSW's Compulsory Third Party (CTP) insurance scheme. Under the MAIA, insurers must fund treatment costs for injuries caused by motor accidents, including medical, physiotherapy, and psychological care. If an insurer denies or limits funding, SIRA can review their decision to ensure it complies with the law.
To challenge a funding decision, you must demonstrate that the insurer's refusal violates the CTP scheme's requirements. SIRA considers factors such as the nature of the injury, the necessity of the treatment, and whether the insurer has followed its obligations under the MAIA. For example, if your doctor has confirmed a treatment plan is medically necessary but the insurer refuses to fund it, this could form the basis of a complaint.
Evidence Needed for a SIRA Complaint
When filing a complaint with SIRA, you must provide evidence to support your case. Key documents include:
- Medical records confirming the injury and treatment plan
- Correspondence with the insurer showing their refusal to fund specific treatments
- Evidence of the insurer's failure to follow its obligations under the MAIA
- Any documentation from your treating medical practitioner supporting the necessity of the treatment
SIRA may also request additional information, such as a copy of the insurer's internal policy on funding decisions. It is important to submit all relevant evidence promptly to strengthen your case.
How SIRA Evaluates Funding Decisions
SIRA assesses whether an insurer's funding decision is lawful by comparing it to the MAIA's requirements. For instance, if the insurer has refused to fund a treatment that is deemed essential under the Motor Accident Guidelines, SIRA may rule in your favor. The insurer must also provide a written explanation for its decision, which you can use to challenge their reasoning.
If SIRA finds the insurer has acted unlawfully, it may direct the insurer to fund the treatment or compensate you for the refusal. In some cases, SIRA may also impose financial penalties on the insurer for non-compliance.
Time Limits and When to Seek Advice
There is no strict time limit for disputing an insurer's refusal to fund treatment, but delays can affect your ability to challenge the decision. It is advisable to act promptly, as SIRA may require evidence that is no longer available after a long period. If you are unsure whether your case meets the criteria for a complaint, seek legal advice to assess your options.
Next Steps
If you believe your insurer has refused to fund your treatment in breach of the CTP scheme, you can contact SIRA directly to file a complaint. However, the process can be complex, and you may need legal assistance to ensure your case is properly prepared. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.