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 the terms of a CTP claim in NSW, claimants must understand their rights and prepare for medical assessments. This guide explains how to navigate disputes with insurers, what evidence matters, and how to prepare for assessments in Albury. SIRA’s guidelines outline the process for resolving treatment-related disputes under NSW CTP laws.
Key CTP Rules Behind Treatment Provider Disputes
Under the Motor Accident Injuries Act 2017, CTP insurers must cover approved treatment for injuries caused by motor vehicle accidents. However, disputes can arise if insurers challenge the necessity, cost, or type of treatment. SIRA’s guidelines clarify that treatment must be clinically reasonable and directly related to the injury. For example, if an insurer disputes a physiotherapy session, claimants must provide evidence linking the treatment to their specific injury.
Practical Steps to Avoid Disputes
To prepare for medical assessments, claimants should:
- Gather medical records showing the injury’s progression and treatment needs
- Document the insurer’s refusal to approve treatment, including dates and reasons
- Obtain a second opinion from a registered medical practitioner
- Complete all required forms promptly to avoid delays
- Keep copies of all correspondence with insurers and treatment providers
SIRA advises that claimants must demonstrate a clear connection between the injury and the treatment. For instance, if a claimant requires ongoing therapy for a soft tissue injury, they must show how the treatment addresses neurological signs outlined in the Motor Accident Guidelines.
Time Limits and Dispute Resolution
CTP claims must be submitted within 52 weeks of the accident under the Motor Accident Injuries Act 2017 s 4.4. If a dispute arises over medical assessments, claimants should:
- Request a written explanation from the insurer
- Submit additional evidence to support their case
- Seek independent medical review through the Personal Injury Commission
- Consider mediation if the insurer refuses to agree
SIRA notes that disputes over treatment are resolved by assessing whether the care is clinically reasonable. Claimants should not delay seeking independent advice if they believe their treatment is being unfairly restricted.
Example Scenario
A claimant in Albury suffered a soft tissue injury and sought acupuncture for chronic pain. The insurer disputed the treatment, arguing it was not covered. The claimant must prove the treatment’s relevance to their injury using medical records and SIRA’s guidelines on acceptable therapies. This example highlights the need for clear documentation linking treatment to the injury.
When to Seek Legal Advice
If an insurer refuses to approve essential treatment or disputes the need for medical assessments, claimants should consult a solicitor. Legal advice can help challenge decisions that breach SIRA’s guidelines or the CTP scheme’s requirements. Always act within the 52-week time limit for submitting claims.
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