CTP TREATMENT CLAIM DENIED?
HERE’S WHAT YOU NEED TO KNOW

THE OVERVIEW

Obtaining prompt access to treatment is critical for an injured person to recover from their motor accident injuries and return to work in a timely manner. Due to the complexity of the NSW motor accident injury scheme, treatment denials are common and require injured people to go through a protracted evidentiary gathering process in order to justify treatment, often resulting in significant delays preventing optimal recovery and return to work outcomes. Understanding why an insurer has denied the treatment and promptly addressing the denial is important if optimal recovery outcomes are to be achieved. An Accredited Specialist like those at Advantage Legal can help if the process appears to overwhelming or difficult.

THE DETAIL

Being injured in a motor accident in NSW can be a traumatic experience. Seeking income support and treatment immediately following the accident is a crucial part of the recovery process. However, if treatment is denied by your Compulsory Third Party (CTP) insurer, everything can suddenly become overwhelming, extremely stressful and confusing, particularly in circumstances where the CTP insurer provides vague or overly legalistic reasoning for the treatment denial.

Reasons for Denial

A car accident injury does not automatically entitle a person to unlimited access to treatment. In the majority of circumstances, an injured person needs to obtain a referral for treatment from their General Practitioner and request approval from the CTP insurer before the treatment is undertaken. The insurer then has 10 days to advise the injured person whether the treatment is approved or not.
If treatment is denied, CTP insurers are required to communicate the reasons for the denial in writing. Unfortunately, as CTP insurers rely heavily on template letters for communicating with injured people, the reasons provided for the treatment denial are often vague or overly legalistic.
Upon receipt of a denial letter from the insurer, the first step is to seek clarification on the reasons for the actual denial. Common denials include:

1. The treatment provider couldn’t be contacted.
2. Insufficient information provided to the insurer to determine why the treatment is required.
3. The treatment appears to be unrelated to the motor accident injuries.
4. The insurer deems the treatment not reasonable and necessary.
5. The cost of the treatment is not approved or exceeds the AMA rates.
6. The treatment is unlikely to result in any improvement in function or return to work capacity.

Many of these issues can be resolved without legal proceedings, however require an injured person to undertake an internal review in order to have the decision overturned.

Review Process

In order to have a treatment decision reconsidered an injured person must request the insurer to conduct an internal review. The internal review process requires the injured person to advise the insurer:

1. What decision is being referred for internal review.
2. The alternate decision sought.
3. The issues under review including elements specific to the injured person’s position.
4. The reasons why the injured person believes the decision should be changed..

The injured person also needs to submit any additional evidence, documents, information or case law relevant to their position for the insurer to consider. A common part of this process is to obtain a letter or report from the treatment provider who proposes to undertake the treatment which addresses:

1. The insurers reasons for denying the treatment and providing an alternate position for consideration.
2. Explaining why the injured person’s individual circumstances ought to be considered instead of applying standard injury management guidelines used by CTP insurers.
3. Any other information relevant to the insurer’s decision.

If the insurer subsequently maintains their treatment denial or alternatively does not respond within the legislated timeframes, the injured person may then proceed to the Personal Injury Commission where the treatment dispute will be determined by an independent Medical Assessor.

Legal Representation

Legal representation isn’t mandatory, however is recommended as treatment disputes quite often involve complex legal issues such as causation (i.e. what caused the injury) which need to be referenced against decided legal precedent. It is also worth noting that without a lawyer you will be arguing your position on your own against a well-resourced insurance company who has trained claims staff, internal lawyers and external law firms at its disposal to argue against you in the Personal Injury Commission.

Legal fees for this kind of dispute are regulated meaning that they are entirely covered by the CTP insurer at the conclusion of the dispute.

THE KEY POINTS TO REMEMBER

1. When a treatment denial is received, clarify the insurer’s reasoning for the denial.
2. Promptly gather all evidence to overturn the decision and request an internal review within 28 days.
3. Engage an Accredited Specialist in Personal Injury Law like the lawyers at Advantage Legal to assist you to gather evidence and request an internal review on your behalf, so you can focus on recovering

Health providers can contact Advantage Legal for free assistance and education seminars on the NSW CTP scheme by emailing info@advantagelegal.com.au