Your physiotherapist recommends another block of sessions. Your GP refers you for a scan. Your surgeon says an operation would help. Then the letter arrives from the insurer saying the treatment will not be funded, and suddenly your recovery is on hold because of a decision made by someone who has never examined you.
It is a frustrating position, and a common one. Treatment refusals are among the most frequently disputed decisions in the New South Wales CTP scheme. The important thing to understand is that a refusal is an opinion formed on the paperwork the insurer happened to have in front of it, and that paperwork is often incomplete. These decisions are regularly overturned, the process for challenging them is free, and you have a clear right to use it.
This guide explains the test the insurer must apply, why treatment gets refused, how to dispute the decision step by step, and the time limits that apply. Please treat it as general information rather than advice about your own claim, because every matter turns on its own medical evidence and circumstances.
The test your insurer has to apply
Treatment and care are part of the statutory benefits available under the Motor Accident Injuries Act 2017 (NSW), the scheme regulated by the State Insurance Regulatory Authority, known as SIRA. Section 3.24 of the Act sets the test, and it has three parts. The treatment must be reasonable, it must be necessary in the circumstances, and it must relate to the injury caused by the motor accident.
That phrase, reasonable and necessary, is doing a lot of work, and it is worth knowing what actually gets weighed. When an insurer or an independent assessor considers a treatment request, the sorts of things taken into account include whether the treatment is appropriate for your particular injury, whether alternative treatments are available and suitable, the cost of the treatment relative to the benefit it offers, and whether it is actually likely to help you, either by improving your condition or by preventing it from getting worse.
Notice what is not part of the test. It is not whether the insurer would prefer a cheaper option, and it is not whether you have already had a lot of treatment. It is a clinical question about your injury and your recovery, which is exactly why medical evidence rather than argument is what changes these decisions.
Your treatment requests are usually submitted by your practitioner using a treatment request form, and the insurer must give you reasons in writing if it declines. Those reasons matter, because they tell you precisely what you need to answer.
Why insurers refuse treatment
Understanding the usual reasons helps you work out whether the decision can be challenged, and how.
The most common problem is simply that the request was not well supported. If the form does not explain why the treatment is needed, what it is expected to achieve, and how it relates to your accident injuries, the insurer may see a request without a rationale and decline it. This is the easiest kind of refusal to fix.
The insurer may say the treatment is not related to the accident. This often happens where you had a pre existing condition, such as earlier back trouble, and the insurer treats your current symptoms as a continuation of that rather than something the crash caused or aggravated.
The insurer may say the treatment is not reasonable or necessary. It might argue you have plateaued, that further sessions of the same therapy are not producing improvement, or that a less expensive alternative would do.
The insurer may rely on its own medical opinion. Where your treating practitioner and an examiner engaged by the insurer disagree, the insurer will often prefer its own report, even though your treating doctors know your recovery far better.
Your entitlement period may have ended. This is the reason people most often misunderstand. If all of your injuries are threshold injuries, or you were wholly or mostly at fault, statutory benefits for treatment generally stop after the first 52 weeks. In that situation the refusal is not really about the treatment at all, it is about your injury classification, and the classification is what needs to be challenged.
Consider a realistic example. A man whose shoulder was injured in a collision is refused approval for surgery. The insurer’s reasons say the request lacks evidence that conservative treatment has been exhausted. His surgeon then provides a short report setting out the treatment already tried, why it has not worked, and what the surgery is expected to achieve. That kind of targeted response addresses the actual reason for refusal, and it is the sort of evidence that can change an outcome. This example is illustrative only and every claim depends on its own facts.
How to dispute a refused treatment decision
There is a defined pathway, and each stage is a genuine opportunity to have the decision changed. In practice it works like this.
- Read the decision letter and identify the exact reason given, because your response has to answer that reason rather than the refusal in general.
- Talk to your treating practitioner. Many refusals are resolved informally when the practitioner provides the clinical detail that was missing from the original request.
- Gather evidence that speaks to the statutory test, explaining why the treatment is appropriate for your injury, what it is expected to achieve, and why it relates to the accident.
- Request an internal review by the insurer, in writing, within 28 days of the decision.
- If that does not resolve it, apply to the Personal Injury Commission for a medical assessment, generally within 28 days of the internal review outcome.
- Get legal advice, particularly where the refusal involves surgery, a pre existing condition, or your injury classification.
The two formal stages are worth explaining further.
Requesting an internal review
Your first formal step is an internal review by the insurer, and you must ask for it within 28 days of the decision. A different person inside the insurer, one who had no involvement in the original decision, reconsiders it and can take new information into account. That last point is the important one. The internal review is your opportunity to put in the supporting report or clinical reasoning that was never before the original decision maker. No legal costs are payable at this stage, and many treatment disputes are resolved here.
Applying to the Personal Injury Commission
If the internal review does not resolve things, you can take the dispute to the Personal Injury Commission, the independent tribunal that decides motor accident disputes in NSW. Because whether treatment is reasonable and necessary is a medical question, it is dealt with as a medical dispute and referred to an independent medical assessor, who is appointed by the Commission rather than chosen by the insurer. The assessor’s determination on the question is binding, and the insurer pays your reasonable costs of attending the assessment. For many disputes at this stage, regulated legal costs may also be payable, which is worth asking about.
A point about treatment that catches people out
There is one feature of the scheme worth knowing early, because it affects how seriously you should take a treatment refusal.
Treatment and care expenses are dealt with through statutory benefits. They are not something you can recover later as part of a common law damages claim. A damages claim covers economic loss and, where the impairment threshold is met, pain and suffering, but your medical and care costs are handled through the statutory benefits stream instead.
The practical consequence is that a refused treatment request is not something you can quietly park and deal with at settlement. If treatment you need is declined and you do not challenge it, that expense does not simply reappear in a lump sum later. It is worth disputing at the time.
Practical steps that improve your chances
Because these decisions are made on paper, the quality of what you put forward is usually decisive.
Ask your practitioner to be specific. A request that says ongoing physiotherapy is far weaker than one that explains what has been achieved so far, what remains limited, what the next block is intended to address, and why it is connected to your accident injuries.
Address any pre existing condition head on. If you had earlier trouble with the same part of your body, silence invites the insurer to assume your symptoms are unrelated. A treating doctor explaining how the accident aggravated a pre existing condition is far more persuasive.
Keep the paper trail. Save the refusal letters, the treatment requests, your certificates and your receipts. If you pay for treatment yourself while a dispute is running, keep every receipt so reimbursement can be sought if the decision is overturned.
Do not let the deadline drift while you wait for a report. Lodge the internal review within 28 days and supplement it with evidence if needed, rather than missing the window.
How Stephen Young Lawyers can help
A treatment refusal is rarely just about one appointment. It can stall your recovery, and where the refusal is really about how your injuries have been classified, it can affect entitlements that run far beyond the treatment itself.
An experienced personal injury lawyer reads the decision for what it actually says, works out whether the issue is the evidence, the causation argument or your injury classification, obtains the medical evidence that answers the statutory test, and runs the dispute through internal review and the Personal Injury Commission where required.
If you want to read more, we have separate guides on how to dispute a CTP insurer’s decision, on what to do when your CTP insurer stops your weekly payments, on disputing a threshold injury decision, and on how CTP compensation payouts are calculated.
Because motor accident injuries often overlap with other entitlements, we can also advise whether you have a related claim. If your accident happened while you were working, you may also have a workers compensation claim alongside your motor vehicle accident claim, and if your injuries have permanently affected your ability to work, a Total and Permanent Disability claim through your superannuation may be available. As an Accredited Specialist personal injury firm based in Sydney CBD, with a multilingual team and a No Win No Fee approach for eligible matters, we can review the refusal and tell you where you stand.
Your recovery should not be paused by a decision made on incomplete information. Change what the insurer is looking at, and the decision can change with it.
Speak with an experienced motor accident lawyer today
If a CTP insurer has refused treatment you need anywhere in New South Wales, do not assume the decision is final, and do not let the 28 day review deadline pass while you are waiting to see what happens.
Contact Stephen Young Lawyers today for a free, no obligation consultation. Call us or get in touch through our website to speak with an experienced personal injury lawyer about the refusal and how to challenge it.