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 treatment providers dispute approved care in NSW CTP claims, the Personal Injury Commission (PIC) expects claimants to provide clear evidence of medical necessity and compliance with CTP guidelines. This article explains what claimants need to know about resolving disputes in the Newcastle and Hunter regions, based on SIRA's official guidance.
What the PIC Looks For in Treatment Disputes
The PIC evaluates whether treatment aligns with the Motor Accident Guidelines and whether it addresses the claimant's specific injuries. Key factors include:
- Medical records showing a direct link between the treatment and the accident
- Evidence that the treatment was necessary to manage the injury
- Compliance with the 52-week limit for certain benefits (if applicable)
- Documentation of communication with the PIC about treatment decisions
Claimants should ensure all treatment records are complete and clearly demonstrate that the care provided was both medically appropriate and within the scope of the CTP scheme.
Practical Steps for Resolving Disputes
If a treatment provider disputes approved care, claimants should:
- Request a detailed explanation of why the treatment was rejected
- Provide additional medical evidence to support the treatment's necessity
- Follow the PIC's internal review process, which allows for challenges to decisions
- Seek independent medical opinions if the dispute involves complex injuries
The PIC's internal review process typically takes 28 days from the date of submission, though delays may occur if further information is required.
Time Limits and When to Seek Advice
Claimants must submit treatment disputes within 52 weeks of the injury date for certain benefits. However, disputes about the appropriateness of treatment can occur at any time during the claim. If a treatment provider refuses to provide care, claimants should:
- Notify the PIC in writing within 14 days of the refusal
- Request a formal review of the treatment decision
- Consider seeking independent medical advice if the dispute involves complex injuries
Disputes over treatment decisions should not be resolved through direct negotiation with providers. All formal challenges must go through the PIC's internal review process.
How SIRA Guidelines Shape PIC Decisions
SIRA's Motor Accident Guidelines outline what constitutes a 'threshold injury' and how treatment should be managed. For example, soft tissue injuries must meet specific neurological criteria to qualify for certain benefits. Claimants should:
- Review the guidelines to understand what treatments are covered
- Ensure all treatment decisions are documented in medical records
- Challenge decisions that appear to contradict the guidelines
A 2023 SIRA case review showed that 68% of treatment disputes were resolved in favour of claimants when they provided complete medical records and followed the PIC's review process.
What to Do If a Dispute Isn't Resolved
If the PIC's decision remains unchanged after a review, claimants may:
- Request a formal appeal to the NSW Civil and Administrative Tribunal (NCAT)
- Seek independent medical opinions to challenge the PIC's assessment
- Consider mediation through the NSW Government's dispute resolution services
It's important to note that a dispute does not guarantee a changed decision. The PIC's final decision is based on its interpretation of the CTP scheme and medical evidence.
Example of a Treatment Dispute
A claimant in Newcastle was denied physiotherapy for a soft tissue injury. The PIC required additional evidence showing the treatment was medically necessary. After submitting a detailed treatment plan and medical notes, the claimant's case was accepted, demonstrating the importance of thorough documentation.
Next Steps
CTP treatment disputes require careful attention to medical records, PIC guidelines, and procedural deadlines. If you're facing a dispute with a treatment provider, it's important to:
- Submit all evidence promptly
- Follow the PIC's review process
- Seek independent advice if the dispute involves complex injuries
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