CTP Treatment Provider Disputes and Time Limits in NSW
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).
If your CTP insurer disputes the treatment provider you've been seeing, you need to understand the time limits for resolving this issue. Under NSW law, there are strict deadlines for challenging or disputing approved treatment. These rules apply across all regions, including Newcastle and Hunter, but practical application may vary based on local SIRA office procedures.
Key Time Limits for CTP Treatment Disputes
The Motor Accident Injuries Act 2017 (MAIA) and SIRA guidelines set clear time frames for resolving treatment disputes. If your insurer refuses to approve a treatment provider, you must act within 28 days of receiving the decision. This period begins when the insurer provides written notice of their refusal. Missing this deadline may prevent you from challenging the decision later.
If the insurer disputes the treatment's necessity or cost, you have 28 days from the date of the insurer's written objection to request a review. This applies to both new treatments and ongoing care. SIRA's internal review process typically takes up to 28 days from the date of the initial objection, but delays can occur in complex cases.
Practical Steps for Resolving Disputes
- Document the dispute: Keep copies of all correspondence with the insurer, including dates and details of their objections.
- Seek medical evidence: Obtain a written opinion from your treating doctor confirming the treatment's necessity and alignment with your injury's clinical needs.
- Submit a formal review request: Use the insurer's official form (usually available on SIRA's website) to formally request a review within the 28-day window.
- Engage the Personal Injury Commission (PIC): If the insurer disputes the medical opinion, you may refer the matter to the PIC for an independent review. The PIC's medical dispute pathway typically takes 30-60 days to resolve.
Consequences of Missing Time Limits
If you fail to act within the 28-day period for disputing treatment decisions, the insurer may refuse to cover the treatment without providing a further review. This could result in reduced weekly benefits or treatment and care benefits after 52 weeks, as outlined in MAIA s 4.4. Additionally, the insurer may argue that the treatment was not 'reasonably necessary' under the threshold injury definition, potentially affecting your overall claim.
Example of a Treatment Dispute
Consider a scenario where a claimant with a soft-tissue injury (confirmed by a spinal nerve-root injury) is denied treatment for chronic pain management. The insurer objects to a psychologist's involvement, citing the Motor Accident Guidelines. The claimant must act within 28 days of the insurer's written objection to request a review. Failure to do so may result in the insurer refusing to cover the psychologist's fees, even if the treatment is clinically appropriate.
When to Seek Legal Advice
If your insurer disputes the treatment provider or refuses to approve care, it's crucial to act quickly. While SIRA provides a pathway for internal reviews, complex disputes may require legal assistance. A solicitor can help you:
- Navigate the SIRA review process
- Challenge the insurer's interpretation of the guidelines
- Explore options for independent medical assessments
Next Steps
Time limits for CTP treatment disputes are strict and vary depending on the nature of the objection. If you're in Newcastle or Hunter and facing a treatment dispute, it's essential to act within the 28-day window to preserve your right to challenge the insurer's decision. Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.