Lodging a SIRA Complaint About Insurer Handling of Treatment and Rehabilitation
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).
If you have been injured in a motor accident in Bega, New South Wales, and believe your insurer has failed to properly manage your medical treatment or rehabilitation plan, you may have grounds to lodge a formal complaint with the State Insurance Regulatory Authority (SIRA). This process is available to claimants who have been assessed as having a threshold injury under the Motor Accident Injuries Act 2017, or who are receiving treatment and care benefits, weekly income payments, or are pursuing a damages claim. SIRA oversees the CTP scheme and investigates complaints about insurer conduct, including decisions about medical treatment, rehabilitation planning, and the provision of support services.
What SIRA Considers in Treatment and Rehabilitation Complaints
SIRA evaluates complaints about insurer handling of treatment and rehabilitation planning based on whether the insurer has met its legal obligations under the CTP scheme. Insurers must act in good faith and ensure that treatment and rehabilitation plans are appropriate, timely, and aligned with medical evidence and the claimant’s recovery needs. Common issues that may be raised include delays in approving treatment, failure to provide access to necessary medical specialists, inadequate coordination of rehabilitation services, or decisions that appear to prioritise cost over recovery outcomes.
SIRA does not substitute its judgment for medical professionals, but it assesses whether the insurer followed the correct process, consulted appropriate medical practitioners, and made decisions based on available clinical evidence. The regulator considers whether the insurer engaged with the claimant, provided clear reasons for decisions, and responded to concerns in a timely manner.
Evidence You Should Prepare for Your SIRA Complaint
To support a complaint about treatment and rehabilitation planning, you should gather and retain the following evidence:
- A copy of your insurer’s treatment and rehabilitation plan, including any correspondence about its development or modification.
- Medical reports from your treating practitioners, including assessments of your functional capacity, prognosis, and recommended treatment.
- A record of all communications with your insurer, including emails, letters, and notes from phone calls, particularly those regarding treatment approval, rehabilitation referrals, or delays.
- Documentation of any delays in receiving treatment, such as appointment letters, waitlist notifications, or evidence of travel to and from appointments.
- A diary or log of your recovery progress, including changes in symptoms, ability to perform daily tasks, and any setbacks linked to delays or inappropriate treatment.
SIRA may request this evidence during its review. It is important to keep all records in a secure and organised file, as they will be critical to demonstrating the insurer’s conduct.
The Process for Lodging a SIRA Complaint
To lodge a complaint, you must use the official SIRA online complaint form available through the SIRA website. You cannot submit a complaint by phone or in person unless you are unable to access the online system and have made a reasonable attempt to do so. The complaint must be submitted within 12 months of the date you became aware of the insurer’s conduct that you believe was improper.
When completing the form, clearly describe the issue, including:
- The date and nature of the motor accident.
- The treatment and rehabilitation plan in question.
- Specific actions or inactions by the insurer that you believe were inappropriate.
- The impact on your recovery, including any worsening of symptoms, loss of function, or delay in returning to work.
SIRA will acknowledge receipt of your complaint and may request additional information. The regulator will assess whether the insurer’s actions were consistent with the Motor Accident Injuries Act 2017 and the Motor Accident Injuries Regulation 2017. SIRA may mediate a resolution, issue a formal determination, or refer the matter to the NSW Civil and Administrative Tribunal (NCAT) if necessary.
What SIRA Can and Cannot Do
SIRA does not determine whether a medical treatment was clinically correct. It assesses whether the insurer followed the proper process, acted in good faith, and made decisions based on reasonable grounds. SIRA cannot order a different medical treatment or force an insurer to fund a specific service. However, it can require the insurer to reconsider a decision, provide a new treatment plan, or compensate you for losses caused by unreasonable delays or failures in planning.
If SIRA finds that the insurer failed to meet its obligations, it may issue a direction requiring the insurer to take corrective action. In some cases, SIRA may recommend that the insurer pay for additional treatment or rehabilitation services that were unjustifiably denied.
A Realistic Example: Delayed Rehabilitation in Bega
For example, a Bega resident was injured in a car accident in June 2024. Their insurer approved a basic physiotherapy program but refused to fund a specialist rehabilitation program recommended by their physiotherapist and a neurologist, citing cost and lack of medical evidence. The claimant was unable to return to work for over 10 months due to ongoing pain and limited mobility. After gathering medical reports, correspondence, and a recovery diary, they lodged a complaint with SIRA. SIRA reviewed the evidence and found that the insurer had not adequately considered the medical advice or engaged with the treating team. SIRA directed the insurer to fund the specialist rehabilitation program and to review the claimant’s treatment plan within 21 days.
When to Seek Independent Advice
If you are unsure whether your insurer’s actions were improper, or if you have been denied treatment or rehabilitation services, it is advisable to seek independent legal or advocacy support. SIRA does not provide legal advice, and you may benefit from assistance in preparing your complaint, understanding your rights, or negotiating with the insurer. Some community legal centres in the South Coast region, including Bega, offer free or low-cost advice on CTP claims.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.