Treatment Provider Disputes in NSW CTP Claims
When an insurer rejects or limits approved treatment for a motor accident injury, caregivers and families may struggle to secure necessary care. Under NSW's Compulsory Third Party (CTP) scheme, treatment providers must be approved by the insurer or the injured person's treating medical practitioner. Disputes often arise when insurers disagree with the type, frequency, or cost of treatment. This guide explains how caregivers can challenge such decisions and navigate the process in regional NSW.
Key CTP Rules Behind Treatment Disputes
The Motor Accident Injuries Act 2017 governs CTP claims, requiring insurers to approve treatment that is 'reasonably necessary' for recovery. SIRA's guidelines state that treatment must be 'medically necessary' and 'reasonably necessary' to achieve the best possible recovery. If an insurer denies treatment, caregivers should first request an internal review. SIRA's 'What you can claim' page confirms that treatment and care benefits are available for injuries meeting the threshold injury criteria, including soft tissue injuries with spinal nerve-root involvement.
Practical Steps for Caregivers and Families
- Document the dispute: Keep records of all communication with the insurer, including dates, times, and details of denied treatments. Note any medical reports supporting the need for specific care.
- Request an internal review: Insurers must provide a written explanation for denying treatment. If the decision remains unchanged, caregivers can escalate the matter to SIRA.
- a Seek independent medical opinion: A second opinion from a registered medical practitioner can challenge the insurer's assessment. SIRA's guidelines emphasize that medical evidence must be 'clear, accurate, and relevant' to the injury.
- Use SIRA's dispute pathway: If the insurer refuses to reconsider, caregivers can apply to the Personal Injury Commission (PIC) for a medical dispute review. The PIC may appoint an independent expert to assess the treatment's necessity.
Time Limits and When to Seek Advice
Insurers must respond to treatment disputes within 28 days of receiving a written request. If the insurer fails to act within this timeframe, caregivers may need to apply to the PIC for a review. Delays in securing treatment can affect long-term recovery, so prompt action is critical. Families should also consider consulting a legal professional if the insurer's refusal appears unreasonable or if the dispute involves complex medical issues.
SIRA Guidance for Caregiver Concerns
SIRA's 'Making a motor accident claim' page clarifies that caregivers have the right to request information about approved treatment providers. If an insurer refuses to provide a list of approved providers, this could be a breach of the CTP scheme's requirements. SIRA also advises that caregivers should not be forced to choose between necessary treatment and financial constraints, as the CTP scheme covers both treatment and income loss benefits.
Example Scenario
A caregiver in regional NSW discovers their loved one's physiotherapy sessions were denied by the insurer. The insurer claims the treatment is 'not medically necessary' despite the injured person's doctor recommending it. The caregiver requests an internal review but is told the decision stands. They then apply to SIRA for a medical dispute review, which appoints an independent specialist to assess the treatment's necessity. The specialist concludes the therapy is required, leading to the insurer approving the sessions.
Next Steps for Caregivers
CTP treatment disputes can be complex, especially in regional areas where access to legal and medical resources may be limited. Caregivers should act quickly to challenge unfair decisions and ensure their loved one receives appropriate care. For personalized guidance, complete the quick, no obligation enquiry form to request contact about your circumstances.