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).
When a treatment provider disputes funding for your motor accident claim under NSW's Compulsory Third Party (CTP) scheme, it can create uncertainty about how to proceed. The CTP scheme determines funding based on medical evidence and statutory guidelines, but disputes can arise if insurers disagree with the treatment plan or cost estimates. This article explains how claimants and treatment providers can resolve such disputes under NSW law, referencing SIRA's interpretation of funding obligations.
How the CTP Scheme Funds Treatment
Under the Motor Accident Injuries Act 2017, treatment providers are entitled to funding for services directly related to the injury caused by the accident. SIRA's Motor Accident Guidelines outline that funding is based on the 'only injuries' test, treatment must be for injuries resulting from the accident. If a provider claims treatment for unrelated conditions, insurers may dispute the funding.
The CTP scheme covers treatment costs for injuries meeting the 'threshold injury' definition, which includes soft tissue injuries like whiplash. However, funding is limited to 52 weeks for injuries that do not meet the whole person impairment threshold. If treatment extends beyond this period, it must be for injuries that meet the higher impairment standard.
Steps to Resolve Funding Disputes
If your treatment provider disputes funding, take these steps:
- Document the treatment plan: Ensure medical records clearly link treatment to the accident-related injury.
- Communicate with the insurer: Request a written explanation for any funding refusal, referencing the Motor Accident Guidelines.
- Seek mediation: SIRA offers a dispute resolution process where independent assessors evaluate claims.
- Escalate to SIRA: If the insurer refuses to fund treatment deemed necessary by your doctor, you can apply for a review through SIRA.
SIRA's Role in Funding Disputes
SIRA interprets funding disputes by assessing whether the treatment is 'reasonably necessary' for the injury. For example, if a provider claims physiotherapy for a soft tissue injury but the insurer argues it's not 'reasonably necessary, ' SIRA will review medical evidence to determine compliance with the Motor Accident Guidelines.
A hypothetical example: A claimant in Auburn receives treatment for a soft tissue injury. The insurer disputes funding for a 12-week physiotherapy plan, arguing it exceeds the 52-week limit. SIRA would review the medical records to confirm whether the treatment is for an injury meeting the 'only injuries' test. If the treatment is for a threshold injury, funding may be approved for the full 52 weeks.
Time Limits and Internal Reviews
Insurers must respond to funding disputes within 28 days of receiving a claim. If they fail to act, claimants can escalate the matter to SIRA. For disputes over medical treatment decisions, the Personal Injury Commission (PIC) oversees internal reviews. However, challenges to SIRA's funding decisions do not guarantee a change. The PIC will assess whether the original decision was legally sound.
When to Seek Legal Advice
Disputes over treatment funding can delay recovery. If your insurer refuses to fund treatment recommended by your doctor, or if you're unsure whether your claim meets the 'only injuries' test, seek legal advice. A solicitor can help you challenge funding decisions or negotiate a fair settlement.
Next Steps
CTP funding disputes depend on the accident date, injury type, and evidence provided. To request contact about your circumstances, complete the quick, no obligation enquiry form.