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 treatment providers or insurers deny, delay or limit approved care for NSW CTP claims, injured people often face confusion about their rights. This article explains how SIRA guidelines address funding conflicts, what steps claimants can take, and when to seek legal advice.
Common Disputes Between Injured People and Treatment Providers
In NSW CTP claims, disputes often arise when treatment providers or insurers:
- Refuse to approve a requested procedure or therapy
- Cap the number of sessions or treatments
- Disagree about the necessity of ongoing care
- Delay or deny payment for services
These conflicts can occur even when the injury is classified as a 'threshold injury' under the Motor Accident Injuries Act 2017. SIRA guidelines state that treatment must be 'reasonably necessary' and 'medically appropriate' to qualify for funding. If a provider or insurer disputes this, claimants may need to provide additional medical evidence to justify the treatment.
How SIRA Handles Treatment Funding Disputes
SIRA's role is to manage the funding of treatment for CTP claims. When a dispute arises about whether a treatment should be funded, the following process applies:
- Medical Evidence Submission: Claimants must provide detailed medical records, including reports from treating doctors, to demonstrate the treatment's necessity.
- Internal Review: SIRA may request an internal review of the treatment plan by its medical advisors. This process considers whether the treatment aligns with the Motor Accident Guidelines.
- Independent Medical Assessment: If the dispute persists, SIRA may arrange for an independent medical opinion to assess the treatment's appropriateness.
It's important to note that SIRA's decisions are not binding on medical practitioners. Doctors and allied health professionals retain clinical discretion, but they must ensure their treatment plans meet SIRA's funding criteria.
Steps to Resolve Treatment Provider Disputes
If you're facing a dispute with a treatment provider or insurer, take these practical steps:
- Document Everything: Keep copies of all medical records, correspondence with insurers, and treatment plans.
- Request a Written Explanation: Ask the provider or insurer to explain why they're disputing the treatment. This helps identify the specific issue.
- Seek a Second Opinion: Consult another medical professional to assess whether the treatment is appropriate.
- Submit a Formal Dispute: Use SIRA's online dispute resolution portal or contact their claims team to formally challenge the decision.
- Consider Legal Advice: If the dispute involves complex medical or legal issues, consult a solicitor specialising in CTP claims.
Time Limits and When to Seek Legal Advice
The Motor Accident Injuries Act 2017 sets time limits for CTP claims. For example, weekly benefits are generally limited to 52 weeks after an injury is classified as a threshold injury (s 4.4). If a dispute affects your ability to receive timely treatment or benefits, you may need to act quickly.
Legal advice should be sought if:
- The insurer refuses to fund essential treatment
- You face a dispute over the type or duration of care
- You need to challenge a decision about your injury's classification
- You're unsure how to proceed with a dispute
Remember, the Personal Injury Commission (PIC) can review medical disputes, but this process is not guaranteed to change a decision. It's important to understand that challenging a decision doesn't automatically result in a different outcome.
Example: A Common Dispute Scenario
Consider a claimant who requires physiotherapy for a soft-tissue injury. The insurer disputes the need for 12 sessions, arguing that 8 are sufficient. Under SIRA guidelines, the claimant must provide evidence that the additional sessions are medically necessary. This might include:
- A doctor's report explaining the injury's progression
- A treatment plan outlining the need for ongoing sessions
- Evidence of how the treatment improves recovery
This example shows how disputes often hinge on proving the medical necessity of treatment, not just the type of care.
Next Steps for Injured Claimants
If you're facing a treatment provider dispute, start by gathering all relevant medical and administrative records. Use SIRA's dispute resolution process to challenge decisions, and seek legal advice if the issue involves complex medical or legal questions. Remember, time limits apply, and early action can help protect your claim.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.