Treatment Provider Disputes in NSW CTP Claims
When insurers dispute the cost, necessity or type of treatment approved under NSW's Compulsory Third Party (CTP) scheme, claimants may face delays or reduced benefits. This article explains how the CTP system handles such disputes, outlines practical steps to resolve them, and provides real-world examples.
How the CTP System Handles Treatment Disputes
Under the Motor Accident Injuries Act 2017, the CTP scheme covers treatment costs for injuries caused by motor vehicle accidents. However, insurers may dispute treatment decisions based on:
- Whether the treatment aligns with SIRA's Motor Accident Guidelines
- Whether the treatment is 'reasonably necessary' under the scheme
- Whether the treatment cost exceeds approved thresholds
Insurers must provide written reasons for declining treatment. If a claimant disagrees, they can:
- Request an internal review by the insurer
- Submit a formal dispute to the Personal Injury Commission (PIC)
- Seek independent medical opinion to challenge the insurer's decision
Practical Steps to Resolve Treatment Disputes
To address a treatment dispute, claimants should:
- Document all communication with the insurer, including dates and reasons for treatment decisions
- Gather medical records showing the necessity of the treatment
- Obtain a second opinion from a registered medical practitioner
- Submit a written request for reconsideration within 28 days of the insurer's decision
Evidence such as medical reports, treatment plans, and correspondence with the insurer are critical. For example, if an insurer disputes a physiotherapy plan, the claimant must show that the treatment was recommended by a doctor as part of the injury management plan.
Time Limits and When to Seek Advice
Claimants must act quickly. Under the CTP scheme:
- Insurers have 28 days to respond to a treatment request
- Claimants have 28 days to request an internal review
- Disputes must be escalated to the PIC within 28 days of the insurer's final decision
If a claimant misses these deadlines, they may lose the right to challenge the insurer's decision. Delays in securing medical treatment or submitting evidence can also jeopardise benefits.
Real-World Example: Dispute Over Physiotherapy
A claimant involved in a car accident was prescribed 12 weeks of physiotherapy. The insurer disputed the cost, arguing that the treatment was 'not reasonably necessary.' The claimant:
- Requested an internal review, providing the doctor's notes
- Submitted a second opinion confirming the treatment's necessity
- Escalated the dispute to the PIC after the insurer refused to reconsider
The PIC reviewed the medical evidence and ruled that the treatment was justified, resulting in full payment of the physiotherapy costs.
Next Steps for Claimants
If your treatment is disputed, act promptly to:
- Submit all required documentation
- Seek independent medical advice
- Escalate disputes within the 28-day window
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.