How NSW CTP Insurers Handle Treatment Provider Disputes
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
When a treatment provider disputes a claimant’s ability to return to daily activities, the NSW Compulsory Third Party (CTP) scheme evaluates the dispute using the Motor Accident Guidelines. Insurers assess whether the claimant’s functional capacity aligns with medical evidence, focusing on whether they can perform essential daily tasks like cooking, shopping, or personal care. Disputes often arise when insurers believe the claimant’s injuries are less severe than reported, or that treatment is unnecessary.
Unique Challenges in Rural and Remote NSW
Claimants in rural areas face additional hurdles. Limited access to specialist treatment providers, long travel distances for appointments, and fewer medical facilities can delay or complicate assessments. For example, a claimant may need to travel 200km for a specialist appointment, impacting their ability to return to daily activities. Insurers may dispute this by arguing the claimant could access care locally, ignoring rural-specific constraints.
SIRA’s Role in Resolving Disputes
The State Insurance Regulatory Authority (SIRA) oversees CTP claims and resolves disputes through its internal review process. SIRA evaluates whether the treatment provider’s assessment of functional capacity is supported by medical records, including doctor’s notes, therapy reports, and evidence of daily activity limitations. Claimants should submit detailed records showing how their injuries prevent them from performing routine tasks.
Practical Steps for Claimants
- Document daily limitations: Keep a journal of tasks you cannot perform due to injuries. For example, if you cannot walk 500 metres without pain, note this.
- Obtain medical evidence: Ensure your treating doctor explicitly links your injuries to daily activity restrictions. A GP note stating ‘the patient cannot cook meals due to hand pain’ is more persuasive than a vague ‘limited mobility’ diagnosis.
- Request internal review: If your insurer disputes treatment, ask for a written explanation of their concerns. SIRA’s guidelines state that insurers must provide evidence for rejecting claims, such as a lack of medical support for the disputed activity.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident for most benefits, though some claims can be made later. If a treatment provider dispute delays your claim, seek legal advice promptly. Under the Motor Accident Injuries Act 2017, insurers must respond to disputes within 28 days, though this deadline may extend if further medical evidence is requested.
Example of a Rural Dispute
Consider a claimant who broke their leg in a rural car accident. Their doctor notes they cannot walk 1km due to pain, but the insurer disputes this, arguing the claimant could walk to the local shop. The insurer ignores that the claimant lives 15km from the nearest shop and has a medical condition requiring crutches. SIRA would likely side with the claimant if the medical records clearly show the injury limits their mobility.
Next Steps
If your claim is disputed, contact SIRA directly to request a review. Rural claimants should also consider consulting a solicitor familiar with CTP disputes to ensure their evidence is properly presented. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.