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 treatment provider agreements or funding in NSW CTP claims, the State Insurance Regulatory Authority (SIRA) provides clear guidelines to resolve conflicts. This article explains how SIRA interprets the Motor Accident Injuries Act 2017 (MAIA) to determine treatment provider agreements, factors considered in disputes, and steps claimants can take to navigate these issues.
SIRA's Role in Resolving Treatment Disputes
SIRA oversees the administration of NSW CTP claims under the MAIA. When a treatment provider disputes an insurer's decision to approve or fund treatment, SIRA evaluates the matter based on clinical guidelines, the claimant's medical needs, and the terms of the treatment agreement. Key factors include:
- Whether the treatment is clinically necessary and aligns with the Motor Accident Guidelines.
- Whether the treatment provider has met the insurer's requirements for documentation and compliance.
- Whether the claimant's injuries meet the threshold for treatment funding under the MAIA.
SIRA's approach prioritizes the claimant's medical needs while ensuring insurers adhere to statutory obligations. For example, if a treatment provider argues that a therapy is essential for recovery, SIRA will assess medical records, clinical notes, and the provider's adherence to agreed-upon treatment plans.
Practical Steps for Claimants
If a treatment provider dispute arises, claimants should:
- Gather all medical records, treatment plans, and correspondence with insurers.
- Ensure treatment providers follow the insurer's documentation requirements.
- Request a written explanation from the insurer for any funding decisions.
- Seek independent medical opinions if disputes persist.
SIRA encourages open communication between claimants, treatment providers, and insurers to resolve conflicts without formal review. However, if disputes escalate, claimants may need to escalate the matter through SIRA's internal review process.
Time Limits and When to Seek Advice
Insurers must respond to treatment funding requests within 28 days under the MAIA. If an insurer refuses funding without a valid reason, claimants can challenge the decision through SIRA. However, time limits apply to all stages of the claims process, so prompt action is essential.
Claimants should also be aware that disputes over treatment agreements may affect long-term benefits. For instance, if a treatment provider is excluded from funding, it could impact weekly income payments or treatment and care benefits. SIRA's guidelines clarify that treatment agreements must be based on the claimant's specific injuries and recovery needs.
Example of a SIRA Dispute Resolution
Consider a scenario where a claimant requires physiotherapy for a soft-tissue injury. The insurer disputes the treatment's necessity, arguing it exceeds the 'threshold injury' definition. SIRA would review the claimant's medical evidence, including imaging and clinical assessments, to determine if the injury meets the MAIA's threshold criteria. If the injury is classified as a threshold injury, SIRA may limit treatment funding to 52 weeks, as outlined in s 4.4 of the MAIA.
When to Seek Legal Advice
While SIRA provides clear guidelines, disputes can become complex. Claimants should consult a legal professional if:
- The insurer refuses funding without a written explanation.
- The treatment provider disputes the insurer's interpretation of the MAIA.
- The claimant's injuries may qualify for long-term benefits but are being excluded.
Legal advice can help claimants understand their rights under the MAIA and ensure treatment providers comply with SIRA's requirements.
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