Treatment provider disputes in NSW CTP claims
If your treatment provider has been denied or capped approval under the NSW Compulsory Third Party (CTP) scheme, you may face challenges accessing necessary care. This guide explains how SIRA resolves disputes, what evidence to preserve, and when to seek legal help.
NSW CTP rules behind treatment disputes
Under the Motor Accident Injuries Act 2017, insurers must approve treatment that meets the Motor Accident Guidelines for injuries caused by a motor accident. A treatment provider dispute arises when:
- The insurer refuses to approve a recommended treatment
- The insurer limits approved treatment to a specific type or duration
- The treatment provider claims the insurer has unreasonably restricted care
SIRA oversees these disputes. If an insurer denies treatment, you can request a review by SIRA within 28 days of the decision. SIRA will assess whether the treatment meets the guidelines and is reasonable for your injury.
Evidence to preserve during disputes
When disputing treatment restrictions, keep detailed records of:
- Medical reports confirming your injury and treatment needs
- Correspondence with the insurer showing denied or capped treatment
- Notes from consultations with your treating doctor
- Evidence of how the restricted treatment affects your recovery
For example, if your physiotherapist says you need 12 weeks of treatment but the insurer caps it at 8 weeks, document how the restricted care delays your recovery. This helps SIRA understand the impact of the dispute.
Time limits and when to seek advice
You have 28 days from the insurer's decision to request a review by SIRA. If the insurer refuses to approve treatment, you can also:
- Request a medical review by the Personal Injury Commission (PIC) to assess your treatment needs
- Seek independent legal advice if the dispute affects your ability to recover
In regional NSW, delays in resolving disputes can worsen injuries. If you're unsure whether your treatment is approved, contact SIRA immediately. Legal advice should be sought if the insurer's decision impacts your long-term recovery or financial stability.
How SIRA resolves treatment disputes
SIRA reviews disputes by:
- Assessing whether the treatment meets the Motor Accident Guidelines
- Considering the medical opinion of your treating practitioner
- Evaluating whether the insurer's decision unreasonably restricts care
If SIRA finds the insurer's decision was unreasonable, it can order the insurer to approve the treatment. However, SIRA cannot order the insurer to pay for treatment that is not medically necessary or exceeds the guidelines.
Practical steps for regional NSW
In regional areas, accessing legal or medical support can be harder. If you're facing a treatment dispute:
- Contact SIRA directly to request a review
- Seek a second opinion from a medical practitioner in your area
- Consider legal advice if the dispute affects your ability to work or manage daily tasks
Remember, the insurer must approve treatment that is reasonable and necessary for your injury. If you believe your treatment is being restricted unreasonably, act quickly to protect your right to care.
When to seek independent legal advice
A lawyer can help if:
- The insurer denies treatment without a clear reason
- The dispute affects your ability to work or manage daily life
- You need help appealing a decision
Legal advice is especially important if the dispute has been ongoing for more than 28 days or if the insurer has refused to engage in discussions. A solicitor can help you understand your options and ensure your rights are protected.
Next steps for injured people in regional NSW
If you're facing a treatment provider dispute under the NSW CTP scheme, take these steps:
- Contact SIRA within 28 days of the insurer's decision
- Gather all medical and correspondence records
- Seek a second medical opinion if needed
- Consider legal advice if the dispute impacts your recovery
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.