Common Disputes Between Injured People and Treatment Providers
When a motor accident occurs in NSW, injured people may need medical treatment to recover. Under the Motor Accident Injuries Act 2017 (MAIA), the Compulsory Third Party (CTP) insurer must fund reasonable and necessary treatment. However, disputes can arise when a treatment provider refuses to provide care, limits the type or duration of treatment, or when the insurer declines to fund a recommended treatment. These disputes are common in Greater Sydney and elsewhere across NSW. Injured people often ask whether they can challenge a provider’s decision, seek a different treatment provider, or request that the insurer fund a treatment not initially approved. The most frequent issues include disagreements over the type of therapy (such as physiotherapy, chiropractic care, or psychological support), the number of sessions approved, or whether a specialist referral should be funded.
How SIRA and the CTP Scheme Handle Treatment Disputes
The State Insurance Regulatory Authority (SIRA) oversees the CTP scheme in NSW and ensures that injured people receive appropriate treatment under the MAIA. If a treatment provider refuses to treat you or limits care, you may have a right to request a review through the insurer or apply to SIRA for a determination. SIRA does not directly provide treatment but can assess whether a treatment is reasonable and necessary under the law. Insurers are required to fund treatment that is clinically appropriate and aligned with the Motor Accident Injuries (MAI) Guidelines. If an insurer denies a treatment request, they must provide a written reason explaining why the treatment is not considered reasonable or necessary. This decision can be challenged through a formal dispute process.
Steps to Take if You Disagree with Your Treatment Provider
If you believe your treatment provider is not acting in your best interests or is refusing to provide care that should be funded, you should take the following steps:
- Contact your CTP insurer in writing to formally dispute the decision. Include a copy of the treatment provider’s written refusal or limitation notice.
- Request a review of the insurer’s decision. Insurers must respond within 28 days of receiving a dispute request.
- If the insurer upholds their original decision, you may apply to the Personal Injury Commission (PIC) for a determination. The PIC has the authority to review whether a treatment is reasonable and necessary under the MAIA and the MAI Guidelines.
- Gather and preserve all relevant evidence: medical reports, treatment plans, correspondence with the insurer and provider, and any documentation showing the treatment was recommended by a medical practitioner.
Can You Switch Treatment Providers Under NSW CTP Rules?
Yes, you can change treatment providers under NSW CTP rules if the current provider is not meeting your needs or has refused to provide approved treatment. You must notify your CTP insurer in writing and request approval to switch providers. The insurer must consider your request and may require a new treatment plan from the new provider. The new provider must be registered with the CTP scheme and provide services that are reasonable and necessary. You are not required to use a provider recommended by the insurer, but you must ensure that the new provider is approved and that the treatment is clinically appropriate. If the insurer refuses to approve a new provider, you can challenge that decision through the PIC.
What Evidence Is Most Important in a Treatment Dispute?
The strongest evidence in a treatment dispute includes:
- A written treatment plan from a qualified medical practitioner, such as a general practitioner, specialist, or allied health professional.
- Documentation showing that the treatment is recommended for your injury and is consistent with the MAI Guidelines.
- A record of all communications with the insurer and treatment provider, including emails, letters, and call logs.
- Medical reports, imaging results, and assessment notes that confirm the ongoing need for treatment.
A medical practitioner’s opinion on the necessity of treatment is critical. If a treatment is not supported by clinical evidence or does not align with accepted medical standards, it may not be funded.
Time Limits and Dispute Timelines
There is no fixed deadline for challenging a treatment decision, but delays may affect your ability to access treatment. Insurers must respond to a dispute within 28 days. If they fail to respond, you may proceed to the PIC. The PIC’s internal review process typically takes 60 to 90 days, depending on the complexity of the case. You should not delay seeking treatment while a dispute is pending, as delays may impact recovery. If a treatment is denied, you may still seek care from a provider willing to treat you on a private basis, but you must keep records to support a later claim for reimbursement.
Hypothetical Example: A Dispute Over Chiropractic Care
A person in Sydney was involved in a motor accident on 15 May 2026. Their GP referred them to a chiropractor for neck and back pain. The CTP insurer approved 10 sessions but refused to fund a further 10 sessions recommended by the chiropractor. The chiropractor submitted a report stating that ongoing care was necessary due to persistent symptoms and imaging showing soft tissue injury. The injured person disputed the insurer’s decision. They wrote to the insurer, attached the report, and requested a review. The insurer upheld the decision. The person then applied to the Personal Injury Commission for a determination. The PIC reviewed the medical evidence and found that the treatment was reasonable and necessary. The insurer was directed to fund the additional sessions.
When to Seek Independent Advice
If you are involved in a dispute about treatment, it is advisable to seek advice from a legal professional or an independent advocate who understands the CTP scheme. Disputes can be complex, and a qualified person can help you understand your rights, prepare a strong case, and navigate the review process. The Personal Injury Commission offers a free dispute resolution service, but it does not provide legal advice. You are not required to have a solicitor, but legal advice can improve your chances of a successful outcome.
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