Common Disputes Between Injured People and 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).
Injured people on the Central Coast often face disputes with treatment providers under NSW CTP laws. Common issues include insurers refusing to approve specific treatments, capping therapy sessions, or delaying payments. For example, an injured person may request physiotherapy for a neck injury but be told their claim is limited to 10 sessions, even though medical records show ongoing pain. These disputes often arise because insurers rely on SIRA’s Motor Accident Guidelines to determine what treatments are 'reasonably necessary' and within the 'threshold injury' definition.
NSW CTP Rules Behind Treatment Provider Disputes
Under the Motor Accident Injuries Act 2017, treatment providers must act in the injured person’s best interests. SIRA regulates disputes by requiring insurers to justify decisions based on medical evidence. If an insurer denies a treatment, they must provide a written explanation referencing the Motor Accident Guidelines. For instance, if a doctor recommends a specialist scan but the insurer refuses, the claimant can challenge this by showing the scan is 'reasonably necessary' under the guidelines.
Practical Steps to Resolve Treatment Provider Disputes
- Document medical advice: Keep copies of all treatment plans, doctor notes, and correspondence with insurers. If a treatment is refused, ask for a written explanation.
- Request a review: Under SIRA’s rules, insurers must review treatment decisions if there’s a disagreement with a medical practitioner. This can be done through the Personal Injury Commission’s internal review process.
- Seek independent medical opinion: If disputes persist, consult a medical practitioner who can confirm whether the treatment is 'reasonably necessary' under the guidelines.
Time Limits and When to Seek Advice
CTP claims must be submitted within 52 weeks of the accident if the injury is a 'threshold injury' (as defined by SIRA). If treatment is delayed beyond this period, weekly benefits may stop, even if the injury is not fully resolved. Injured people should act quickly: contact SIRA directly to challenge a treatment decision, or seek legal advice if the insurer refuses to review their case. Disputes over treatment plans can also be escalated to the Personal Injury Commission for a formal review.
Example: Resolving a CTP Treatment Dispute
Consider a cyclist on the Central Coast who suffered a soft-tissue injury. Their doctor recommends 20 sessions of physiotherapy, but the insurer approves only 10. The claimant can challenge this by showing the doctor’s notes confirm ongoing pain and limited mobility. SIRA’s guidelines state that treatment must be 'reasonably necessary' to manage the injury, so the claimant can argue the 20 sessions are needed. If the insurer refuses to review, the claimant can request a formal review through the Personal Injury Commission.
When to Seek Legal Advice
If disputes over treatment plans lead to financial hardship or prevent access to necessary care, injured people should seek legal advice. A solicitor can help challenge an insurer’s decision, ensure treatment is approved, or negotiate a fair outcome. Legal advice is also essential if the insurer refuses to review a treatment decision or if the claimant is unsure whether their dispute is valid under SIRA’s rules.
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