Vision Loss Treatment Costs in NSW CTP Claims
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 you have suffered vision loss as a result of a motor accident in New South Wales, you may be entitled to funding for treatment and care under the Compulsory Third Party (CTP) insurance scheme. This funding covers a range of medical and therapeutic expenses related to your eye injury, including specialist consultations, surgical procedures, vision rehabilitation, and ongoing therapy. The Motor Accident Injuries Act 2017 (MAIA) governs these entitlements, and the State Insurance Regulatory Authority (SIRA) administers the scheme across NSW.
What Treatment Costs Are Covered?
Under the CTP scheme, you may be funded for treatment costs that are directly related to your vision loss injury, provided they are reasonable, necessary, and appropriate. This includes:
- Specialist eye assessments and diagnostic tests (such as OCT scans or visual field testing)
- Surgical interventions to repair eye trauma or address complications
- Ongoing medical management by ophthalmologists or neuro-ophthalmologists
- Vision rehabilitation services, including low-vision aids and training
- Psychological support if vision loss has caused significant mental health impact
Funding is not limited to initial treatment. It extends to any care that is clinically indicated and documented as part of a treatment plan approved under the CTP scheme. All treatment must be authorised through the insurer or SIRA’s claims management process.
How SIRA Funds Treatment Expenses
SIRA does not directly pay treatment providers. Instead, it oversees the CTP insurer’s responsibility to fund eligible treatment through a structured claims process. The insurer must assess and approve treatment plans based on medical evidence and the Motor Accident Injuries Regulation 2017.
To access funding, you must:
- Report the accident to your insurer within a reasonable time
- Obtain a formal medical assessment from a qualified practitioner
- Submit a treatment plan to the insurer for approval
- Receive written confirmation of approval before commencing treatment
SIRA provides guidance on the types of evidence required, including medical reports, itemised invoices, and progress notes. Insurers are required to act in good faith and respond to claims within a reasonable timeframe, though delays may occur if documentation is incomplete.
Limits on Treatment Funding
There are limits on how long treatment funding may be available, depending on the nature and severity of the injury. For people with a threshold injury (such as a soft-tissue injury to the neck or back), funding for treatment and care benefits may be limited to 52 weeks from the date of the accident, unless the injury results in a permanent impairment.
Vision loss from a motor accident is not classified as a threshold injury under the Motor Accident Injuries Act 2017. Therefore, treatment funding is not subject to the 52-week limit. Instead, funding continues as long as the treatment remains clinically necessary and supported by medical evidence. However, if your only injuries are threshold injuries and vision loss is not independently attributable to the accident, funding may be restricted.
In cases where vision loss is linked to a more serious neurological injury, such as a brain injury affecting visual processing, funding may extend beyond initial treatment. The insurer must consider the long-term nature of the condition and any need for ongoing rehabilitation.
Practical Steps and Evidence That Matter
To secure funding for treatment, you should:
- Seek medical attention immediately after the accident, even if vision loss is not immediately apparent
- Keep all medical records, including appointment notes, test results, and treatment plans
- Take photographs of the accident scene, vehicle damage, and any visible injuries
- Obtain contact details of witnesses
- Notify your insurer as soon as possible, ideally within 28 days
- Request a written record of all communications with the insurer
A documented treatment plan from a specialist ophthalmologist or neuro-ophthalmologist is critical. It must clearly link the treatment to the accident and demonstrate medical necessity. Without this, approval may be delayed or denied.
Time Limits and Dispute Options
While there is no strict deadline for applying for treatment funding, you must notify your insurer of the accident within a reasonable time. Delays may affect the insurer’s ability to investigate and approve claims, particularly if evidence is lost or witnesses are no longer available.
If your claim for treatment funding is denied or delayed, you may request a review from the insurer. If unresolved, you can apply to the Civil and Administrative Tribunal (NCAT) for a determination under the MAIA. You may also seek assistance from an independent legal adviser or a community legal centre.
Hypothetical Example
A 42-year-old cyclist was struck by a car in a Sydney car park. The impact caused a retinal detachment and partial vision loss in one eye. The cyclist sought treatment within a week, was diagnosed by an ophthalmologist, and received a treatment plan including surgery and post-operative rehabilitation. The insurer approved funding for all treatment costs after reviewing medical evidence. The funding continued for 18 months, including follow-up care and vision therapy, as the injury was not a threshold injury and required ongoing management.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.