How SIRA Resolves Treatment Funding Disputes in NSW
Where a person's only injuries resulting from the accident are threshold injuries, weekly benefits and treatment and care generally cease after 52 weeks (ss 3.11 and 3.28).
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).
If you're in Ashfield and facing a dispute over funding for medical treatment under your NSW Compulsory Third Party (CTP) claim, the State Insurance Regulatory Authority (SIRA) oversees the process. SIRA ensures treatment costs are approved in line with the Motor Accident Injuries Act 2017 and the Motor Accident Guidelines. Disputes often arise when insurers deny or limit funding for treatments like physiotherapy, psychology, or specialist consultations. SIRA evaluates whether the treatment is medically necessary and within the scope of the claim.
Practical Steps for Claimants in Ashfield
To address a treatment funding dispute, follow these steps:
- Document all treatment details: Keep records of medical reports, invoices, and correspondence with healthcare providers.
- Submit a formal dispute request: Use SIRA’s online portal or contact them directly to challenge the insurer’s decision.
- Request a review: SIRA may require a medical report from your treating practitioner to assess the treatment’s necessity.
- Seek independent medical opinion: If the dispute escalates, a second opinion from a registered medical practitioner may be necessary.
Legal Boundaries and Time Limits
Under NSW law, treatment costs must be approved within 52 weeks of the accident if they are classified as 'threshold injuries' (minor soft-tissue injuries). For more severe injuries, funding is available for longer. However, insurers may dispute costs if:
- The treatment is not listed in the Motor Accident Guidelines
- The injury does not meet the 'threshold injury' criteria
- The treatment is deemed unnecessary or excessive
If your dispute involves a 'threshold injury, ' SIRA will assess whether the treatment aligns with the guidelines. Note that time limits apply: disputes must typically be resolved within 52 weeks for threshold injuries, though exceptions exist for complex cases.
Example Scenario: A Claimant’s Dispute
Consider a claimant in Ashfield who sustained a soft-tissue injury in a car accident. Their physiotherapist recommends 12 sessions, but the insurer approves only six. The claimant disputes this, arguing the full course is needed. SIRA reviews the physiotherapist’s notes and may request a medical report confirming the treatment’s necessity. If the evidence supports the claimant’s case, SIRA may approve the full funding.
When to Seek Legal Advice
While SIRA handles most disputes, complex cases may require legal assistance. A solicitor can help if:
- The insurer refuses to engage with SIRA
- The dispute involves long-term treatment or lifetime care
- You believe the insurer is acting in bad faith
Legal professionals can also assist with drafting formal dispute requests and ensuring all evidence is properly submitted.
Next Steps for Claimants
If your treatment funding is disputed, act promptly. SIRA’s process can take time, and delays may affect your ability to access necessary care. Gather all medical records and contact SIRA immediately. For personalized guidance, complete the quick, no obligation enquiry form to discuss your circumstances.