How to Resolve Treatment Provider Disputes in NSW CTP Claims
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).
If your Compulsory Third Party (CTP) claim in New South Wales is being challenged over treatment costs or providers, you need to understand your rights under the Motor Accident Injuries Act 2017. SIRA (State Insurance Regulatory Authority) oversees CTP claims and provides clear guidelines for resolving disputes. This article explains how to address disagreements with treatment providers, with practical examples relevant to rural and remote NSW.
Key NSW CTP Rules for Treatment Disputes
Under the CTP scheme, insurers must approve treatment providers and cover medically necessary care. However, disputes often arise when:
- The insurer rejects a recommended specialist
- The treatment cost exceeds the insurer’s approved rate
- The claimant’s rural location limits access to approved providers
SIRA’s guidelines state insurers must justify rejections with medical evidence. For example, if a rural claimant needs a specialist not available locally, the insurer must provide a valid reason to deny treatment. The Motor Accident Injuries Act 2017 s 4.4 also limits benefits after 52 weeks if only threshold injuries are involved, but this does not apply to ongoing treatment disputes.
Practical Steps for Rural/Remote Claimants
- Document all treatment records - Keep copies of medical reports, invoices, and correspondence with insurers. Rural claimants may need to provide evidence of limited local specialist access.
- Request a written explanation - If an insurer rejects a treatment provider, ask for a detailed reason. SIRA requires insurers to provide medical evidence for rejections.
- Seek second opinions - If you disagree with the insurer’s assessment, consult another medical practitioner. SIRA’s guidelines allow claimants to challenge decisions with new evidence.
- a Submit a formal dispute - Use SIRA’s online dispute resolution tool or contact them directly. Rural claimants should note delays in processing claims due to remote locations.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident (s 3.28). However, disputes over treatment can extend beyond this period if resolved through internal reviews. If your insurer refuses to cover treatment, you have 28 days to request a review (s 3.29). For complex rural disputes, seek legal advice before the 52-week deadline to ensure all evidence is submitted.
Example: Rural Claimant Fights Denied Physiotherapy
A claimant in Dubbo sustained a soft-tissue injury and sought physiotherapy. The insurer denied coverage, arguing the treatment was ‘non-essential.’ The claimant submitted medical records showing limited local physiotherapy options and a doctor’s note confirming the treatment was necessary. SIRA reviewed the evidence and ruled in the claimant’s favor, highlighting that rural access limitations must be considered.
Next Steps for Claimants
If your treatment dispute is unresolved, contact SIRA directly or consult a solicitor. Rural claimants may face additional hurdles, such as longer travel times to specialist appointments. Always keep detailed records and act within the 52-week deadline to preserve your CTP entitlements.
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