When treatment providers dispute claims under NSW's Compulsory Third Party (CTP) scheme, the Primary Insurance Claimant (PIC) has specific expectations for resolving disputes. This article explains what evidence and procedures the PIC typically requires, focusing on Western Sydney.
What the PIC Requires in Treatment Provider Disputes
The PIC expects claimants to provide clear documentation showing the treatment is medically necessary and directly related to the accident. This includes medical records, treatment plans, and evidence of the provider's compliance with SIRA guidelines. For example, if a physiotherapist declines to treat a claimant for a soft tissue injury, the PIC may require proof the treatment aligns with the Motor Accident Guidelines.
How PICs Assess Treatment Claims
PICs evaluate treatment validity by checking if the care meets the 'threshold injury' criteria under the Motor Accident Injuries Act 2017. This means the injury must be one that would typically require treatment, such as a whiplash or sprain. If a dispute arises over the type or duration of treatment, the PIC may request a medical report confirming the treatment's necessity.
Practical Steps for Resolving Disputes
Claimants should first attempt to resolve disputes directly with the treatment provider. If unsuccessful, they may need to escalate the issue to the PIC's internal review process. Key evidence includes:
- Medical records showing the injury's connection to the accident
- Treatment provider's records of the claimant's history
- Correspondence with the PIC about the dispute
Time Limits and When to Seek Advice
Disputes must typically be resolved within 52 weeks of the accident if the injury is classified as a 'threshold injury.' If the claimant's only injuries are threshold injuries, weekly benefits may stop after 52 weeks. Claimants should seek legal advice if disputes persist beyond this period or if the PIC denies treatment coverage.
Example of a PIC Dispute
A claimant in Western Sydney sought treatment for a soft tissue injury but was told their claim was 'not approved.' The PIC required the claimant to provide a medical report confirming the injury met the threshold criteria. After submitting the report, the PIC approved the treatment.
Next Steps
If your treatment provider disputes your CTP claim, gather all medical and administrative records. The PIC's decision may depend on whether your treatment aligns with SIRA guidelines. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.