Common Disputes Between Injured People and CTP Treatment Providers
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
When a motor accident claim is made under NSW’s Compulsory Third Party (CTP) scheme, disputes often arise between injured claimants and approved treatment providers. These conflicts typically involve disagreements over treatment plans, documentation requirements, or whether a provider is eligible to deliver care under the scheme. For example, an injured person might believe their physiotherapist is not providing adequate care, while the insurer insists the provider meets all CTP guidelines. Such disputes can delay recovery and create confusion about next steps.
How SIRA Handles Disagreements
The State Insurance Regulatory Authority (SIRA) oversees the CTP scheme and has specific processes for resolving treatment-related disputes. Under the Motor Accident Injuries Act 2017, SIRA must approve treatment providers and ensure their services align with the scheme’s guidelines. If a claimant disagrees with a provider’s approach or documentation, they can request a review by submitting evidence such as medical records, treatment plans, and correspondence with the insurer. SIRA may also consult with medical experts to assess whether the treatment meets the scheme’s standards.
Practical Steps to Resolve Disputes
- Document Everything: Keep detailed records of all treatment sessions, including dates, diagnoses, and progress notes. This helps demonstrate that the treatment aligns with the injury’s needs.
- Communicate with the Insurer: If a provider is refusing to accept CTP payments or altering treatment plans, contact the insurer’s claims team. They must provide a written explanation for any refusal.
- Request a Review: Under the CTP scheme, claimants can formally request a review of the treatment plan. This involves submitting a written application to SIRA, outlining the dispute and supporting evidence.
- Seek Independent Medical Advice: If there’s a disagreement about the necessity of treatment, consult a medical practitioner not involved in the claim. Their opinion can strengthen a dispute resolution request.
Time Limits and When to Seek Advice
The CTP scheme has strict time limits for certain benefits. For example, weekly income payments and treatment benefits are generally limited to 52 weeks after an injury is classified as a ‘threshold injury’ under the Motor Accident Guidelines. If a dispute arises after this period, claimants may need to explore other options, such as applying for a personal injury claim under common law. It’s crucial to address disputes promptly, as delays can affect eligibility for benefits.
Example Scenario: Resolving a Treatment Dispute
Consider a scenario where an injured person in Ballina is referred to a physiotherapist by their insurer. After several weeks, the claimant believes the treatment is not addressing their chronic pain and requests a change. The insurer refuses, citing the provider’s compliance with CTP guidelines. In this case, the claimant should:
- Submit a written request to SIRA explaining the disagreement.
- Provide medical evidence showing the treatment’s ineffectiveness.
- Seek a second opinion from a different provider.
SIRA will then review the evidence and may adjust the treatment plan or approve an alternative provider.
When to Seek Legal Advice
While SIRA handles most disputes through its internal review process, complex cases may require legal assistance. A solicitor can help navigate situations where the insurer’s refusal is unreasonable or where the claimant’s rights under the CTP scheme are being overlooked. Legal advice is particularly valuable if the dispute involves a disagreement over the classification of an injury or the calculation of benefits.
Final Steps for Injured Claimants
If you’re facing a dispute with your CTP treatment provider, the first step is to gather all relevant documentation and submit a formal request for review. SIRA’s process is designed to be fair and transparent, but it’s important to act quickly to avoid missing time-sensitive deadlines. For personalized guidance, complete the quick, no obligation enquiry form to discuss your specific circumstances.