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).
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 treatment providers dispute funding decisions for rehabilitation under NSW's Compulsory Third Party (CTP) scheme, claimants and providers must navigate SIRA's guidelines. This article explains how disputes are resolved, the steps to challenge decisions, and how rehabilitation planning affects treatment funding.
How SIRA Handles Treatment Provider Disputes
SIRA (State Insurance Regulatory Authority) oversees CTP claims under the Motor Accident Injuries Act 2017. If a treatment provider disputes a funding decision, they must first seek internal review through the insurer. SIRA's guidelines state that rehabilitation planning must align with the 'reasonable and necessary' standard, prioritizing evidence-based care. For example, if a physiotherapist argues that a proposed therapy is not 'reasonable', SIRA assesses whether the treatment meets clinical guidelines and the claimant's injury profile.
Key Steps to Resolve Treatment Provider Disputes
- Internal Review: Insurers must respond to disputes within 28 days, providing written reasons for funding decisions. This process allows providers to challenge decisions based on medical evidence.
- Medical Evidence: Providers must submit clinical records, treatment plans, and expert opinions to demonstrate that the proposed care meets SIRA's 'reasonable and necessary' threshold. For instance, a dispute over prolonged therapy may require a specialist's opinion on the injury's long-term prognosis.
- External Review: If the insurer rejects the dispute, claimants can request a review by the Personal Injury Commission (PIC), which has the authority to overturn decisions. However, the PIC does not provide new evidence but assesses whether the insurer applied the law correctly.
SIRA's Rehabilitation Planning Requirements
SIRA's rehabilitation planning guidelines (available on SIRA's website) require insurers to consider the claimant's 'whole person impairment' and long-term needs. For example, a claimant with a soft-tissue injury (threshold injury) may require ongoing physiotherapy, but funding may be limited after 52 weeks unless the injury meets the 'whole person impairment' threshold. Providers must ensure treatment plans explicitly link to the injury's severity and recovery timeline.
Time Limits and Dispute Resolution
Disputes must be resolved within strict timeframes. Insurers have 28 days to respond to internal reviews, and claimants have 90 days from the initial funding decision to request a PIC review. Delays beyond these periods may jeopardize the claimant's ability to challenge decisions. SIRA also emphasizes that disputes must be resolved through the insurer's internal process before escalating to the PIC.
Practical Example: A Hypothetical Case
Imagine a claimant with a spinal nerve-root injury (qualified as a threshold injury) disputes an insurer's refusal to fund 12 weeks of physiotherapy. The provider submits medical records showing the injury meets the 'neurological signs' criteria under the Motor Accident Guidelines. SIRA reviews the evidence and finds the treatment is 'reasonable', leading to a funding decision. This example illustrates how clinical documentation directly impacts funding outcomes.
When to Seek Legal Advice
While SIRA provides clear guidelines, disputes often require legal expertise. Claimants should consult a solicitor if: (1) the insurer rejects an internal review, (2) the claimant's injury exceeds the threshold injury criteria, or (3) the dispute involves complex rehabilitation planning. Legal advice ensures all procedural and evidentiary requirements are met.
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