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 a treatment provider and a CTP insurer disagree on rehabilitation planning, injured people in NSW must understand their rights and options. The Motor Accident Injuries Act 2017 and SIRA guidelines define how insurers assess treatment necessity, but disputes often arise when plans conflict with approved medical advice. This article explains how to address such conflicts, including steps to take and evidence to gather in Western Sydney.
How CTP Insurers Evaluate Treatment Plans
CTP insurers must approve treatment plans that align with the Motor Accident Guidelines. Under the Motor Accident Injuries Act 2017 s 4.4, insurers cannot refuse treatment unless it is not reasonably necessary. SIRA’s guidelines clarify that treatment must be 'medically necessary' and 'reasonably necessary' to meet the threshold injury criteria. For example, if a physiotherapist recommends a 12-week program but the insurer caps it at 8 weeks, the claimant must demonstrate the full plan meets clinical standards.
Practical Steps for Claimants
If your treatment plan is disputed, take these steps: First, review the insurer’s refusal letter to identify specific concerns. Second, consult your treating medical practitioner to confirm the plan meets SIRA’s 'reasonably necessary' standard. Third, submit a written explanation of how the plan addresses your injury, referencing medical records and the Motor Accident Guidelines. In Western Sydney, some insurers use the 'rehabilitation planning tool' on SIRA’s website to assess proposals, so familiarise yourself with its criteria.
Evidence to Support Your Case
Key evidence includes: medical reports detailing the injury’s severity, treatment records showing the plan’s progression, and any correspondence with the insurer. If the insurer disputes a specific therapy, provide clinical guidelines supporting its use. For instance, if a claimant requires a specialist referral but the insurer refuses, evidence of the specialist’s role in the treatment plan is critical. Keep all documents, as insurers may later challenge the necessity of care.
Time Limits and Dispute Resolution
CTP insurers must respond to treatment requests within 28 days under the Motor Accident Injuries Regulation 2017. If they fail to act, you may need to escalate the matter. SIRA’s internal review process allows claimants to request a reassessment of denied treatment. However, note that the Personal Injury Commission’s medical dispute pathway does not guarantee a change in decisions. Disputes often require mediation or legal review, but these options are not guaranteed.
When to Seek Legal Advice
If your insurer refuses to cover agreed-upon treatment, or if disputes over rehabilitation planning affect your recovery, consult a solicitor. Legal advice can help you challenge an insurer’s refusal or negotiate a revised plan. Remember, the 52-week statutory benefit period under s 3.28 applies only to threshold injuries, so prolonged disputes may impact long-term entitlements.
Example Scenario
Consider a claimant in Western Sydney who sustained a soft-tissue injury and was advised a 10-week physiotherapy plan. The insurer refused, citing 'no evidence of ongoing impairment.' The claimant’s doctor then provided a report confirming the injury meets the spinal nerve-root criteria in the Motor Accident Guidelines. By submitting this evidence, the claimant secured approval for the full plan, demonstrating how SIRA’s framework resolves such disputes.
Next Steps
CTP treatment disputes depend on the accident date, injury type, and insurer actions. To request contact about your circumstances, complete the quick, no obligation enquiry form.