Common mistakes in CTP treatment provider disputes
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).
When insurers dispute or limit approved treatment for a motor accident injury in New South Wales, injured persons often make errors that weaken their claim. These mistakes can delay recovery, reduce compensation, or even result in denied benefits. Understanding the legal framework and practical steps can help avoid these pitfalls.
Key mistakes to avoid
- Failing to document treatment details. Insurers require detailed records of all medical treatments, including dates, providers, and costs. Without thorough documentation, disputes over treatment necessity or cost may arise. For example, an injured person might stop attending therapy sessions before completing a recommended course, leading to claims that treatment was unnecessary.
- Not following SIRA’s approved treatment guidelines. The State Insurance Regulatory Authority (SIRA) sets rules for what treatments are eligible under the Motor Accident Injuries Act 2017. Disputes often occur when treatment exceeds SIRA’s defined scope, such as using unapproved therapies or extending care beyond the 52-week statutory limit for weekly benefits.
- Ignoring communication with insurers. Delays in submitting medical reports or failing to respond to insurer requests for information can create the impression of non-cooperation. Insurers may dispute treatment if they believe the injured person is not following the claims process.
- Not seeking independent medical assessments. When disputes arise over the necessity of treatment, an independent medical opinion can clarify whether care was appropriately provided. Failing to request such an assessment may leave the injured person without evidence to challenge an insurer’s decision.
Legal framework for treatment disputes
Under the Motor Accident Injuries Act 2017, insurers must approve treatment that is 'reasonably necessary' for recovery. SIRA’s guidelines define what constitutes 'reasonably necessary' care, including physiotherapy, occupational therapy, and medical equipment. If an insurer disputes treatment, they must provide a written explanation of their concerns. Injured persons have the right to request a review of the insurer’s decision through SIRA’s internal review process.
The 52-week statutory limit for weekly benefits applies only to injuries that meet the 'threshold injury' definition under the Motor Accident Guidelines. If an injury is not a threshold injury, weekly benefits may continue beyond 52 weeks. Confusing these rules can lead to disputes over whether treatment should continue.
Practical steps to avoid disputes
- Keep detailed medical records: Maintain copies of all medical reports, treatment plans, and correspondence with healthcare providers. This evidence can prove that treatment was necessary and followed SIRA’s guidelines.
- Communicate with insurers: Respond promptly to insurer requests for information. If an insurer questions a treatment, provide additional documentation to support its necessity.
- Seek independent assessments: If an insurer disputes treatment, request an independent medical opinion. This can clarify whether care was appropriately provided and help resolve disputes.
- Understand SIRA’s review process: If an insurer denies or limits treatment, you can request a review through SIRA. The review process typically takes up to 28 days and may involve a medical expert’s opinion.
Time limits and when to seek advice
There are no strict time limits for disputing treatment decisions, but delays can weaken your case. For example, if an insurer disputes treatment after 52 weeks, you may need to demonstrate that the injury is not a threshold injury. Seeking legal advice early can help navigate these complexities.
In Western Sydney, injured persons should be aware that insurers may use local medical networks to assess treatment. If you believe an insurer is unfairly limiting care, consult a solicitor specialising in CTP claims. They can help challenge decisions and ensure you receive appropriate treatment.
Hypothetical example
Consider an injured person who stops attending physiotherapy sessions after 12 weeks, believing they no longer need treatment. The insurer later disputes the necessity of care, arguing that the treatment was not 'reasonably necessary' under SIRA’s guidelines. In this case, the injured person may need to provide evidence that their condition required ongoing therapy, such as medical reports showing continued pain or limited mobility.
When to seek independent advice
If an insurer denies or limits treatment, it’s important to seek legal advice. A solicitor can help you:
- Challenge the insurer’s decision through SIRA’s review process;
- Request an independent medical assessment;
- Understand your rights under the Motor Accident Injuries Act 2017;
- Ensure you receive all eligible benefits, including treatment and care payments.
Next steps
CTP treatment disputes can be complex, especially when insurers challenge the necessity of care. By understanding the legal framework, documenting treatment, and seeking independent advice when needed, injured persons can avoid common mistakes. If you’re in Western Sydney and facing a treatment dispute, contact a solicitor specialising in CTP claims to explore your options.
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