Understanding CTP Treatment Provider Disputes in NSW
If your motor accident treatment provider is denied, capped or delayed by the Compulsory Third Party (CTP) insurer, you may need to dispute the decision. In New South Wales, the Motor Accident Injuries Act 2017 (MAIA) governs CTP claims, including disputes over treatment and care. Insurers may refuse treatment based on medical guidelines, cost, or perceived lack of necessity. However, you have the right to challenge these decisions. The dispute process is governed by the Motor Accident Injuries Regulation 2017 and the Motor Accident Guidelines issued by the State Insurance Regulatory Authority (SIRA). These documents set out the criteria for treatment approval and the process for review.
Essential Evidence and Records to Preserve
To support a dispute with your CTP insurer over treatment, you must keep clear, accurate and complete records. The following evidence is typically required:
- A copy of your CTP insurer’s written decision denying, limiting or delaying treatment.
- All correspondence with the insurer, including emails, letters and SMS messages related to treatment approval.
- A detailed record of all medical appointments, including dates, times, practitioners, and treatment notes.
- Medical reports and assessments from your treating practitioner, including a statement of clinical need for the treatment.
- Photographs of the accident scene, vehicle damage, or injury symptoms, if relevant.
- Witness contact details and statements, if available.
- Pay slips or income records, if treatment is affecting your ability to work.
- A diary or log of symptoms, pain levels, and functional limitations, particularly if treatment is affecting daily activities.
SIRA advises that medical evidence must demonstrate a direct link between the treatment and injuries sustained in the motor accident. The treating practitioner’s report must explain why the treatment is clinically necessary and how it supports recovery or functional improvement.
How to Respond to a Treatment Dispute
If your insurer denies or limits treatment, you must act promptly. Under the MAIA, you have the right to request an internal review from the insurer within 28 days of receiving the decision. The insurer must respond within 21 days. If the internal review upholds the original decision, you may apply to the Personal Injury Commission (PIC) for a review of the treatment decision. The PIC is the independent body that handles disputes about treatment, care and medical assessments under the CTP scheme.
To apply to the PIC, you must submit a formal application, including all supporting evidence. The PIC will assess whether the treatment is reasonable, necessary and appropriate under the Motor Accident Guidelines. You may be required to attend a medical assessment with a specialist nominated by the PIC. The PIC’s role is to determine whether the insurer’s decision was correct under the law and guidelines.
Time Limits and Procedural Requirements
There are strict time limits for disputing treatment decisions. You must request an internal review within 28 days of receiving the insurer’s decision. If you do not, you may lose the right to challenge the decision through formal review. The PIC has a 60-day time limit to make a decision on a treatment dispute, but this may be extended if additional medical evidence is required.
Failure to act within these timeframes may result in the treatment being withheld permanently. Insurers are not required to provide a reason for a treatment cap or denial in every case, but they must follow the Motor Accident Guidelines. If you believe the insurer has not followed the guidelines or made an error in assessment, you may seek independent medical advice to support your case.
When to Seek Legal Advice
While you are not required to have a solicitor to dispute a treatment decision, legal advice can help you understand your rights, prepare evidence, and navigate the review process. A solicitor can assist with drafting submissions, arranging medical assessments, and representing you at a PIC review hearing. The decision to seek advice should be based on the complexity of your case, the nature of the treatment in dispute, and whether your injury is affecting your ability to work or perform daily activities.
A common example: A pedestrian in Sydney was injured in a car park in November 2024. Their treating physiotherapist recommended 12 weeks of hydrotherapy. The CTP insurer declined the treatment, stating it was not clinically necessary. The claimant kept all appointment notes, a letter from the physiotherapist explaining the treatment’s role in recovery, and a diary of pain and mobility issues. They requested an internal review within 28 days and later applied to the PIC. The PIC upheld the treatment recommendation after reviewing the medical evidence and the Motor Accident Guidelines.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.