Following an injury, access to prompt and suitable treatment is very important to aid in your recovery. Under the Queensland Compulsory Third Party (CTP) scheme the Insurer must fund reasonable medical and rehabilitation expenses once liability for the accident has been admitted (which means that the Insurer admits that their insured driver was at fault, or partially at fault, for the accident).
Unfortunately, CTP Insurers regularly refuse funding for treatment even where recommendations for the treatment are made by your treating medical professionals. Our experienced personal injury lawyers have extensive experience and success in challenging decisions of the Insurers and, if necessary, applying to the Court to ensure that appropriate funding is provided.
Obligations of the Insurer
The CTP Insurer is not obliged to fund medical and treatment expenses until liability for the accident is admitted. However, in most cases the Insurer will offer to fund rehabilitation expenses (for example physiotherapy) within a few weeks of your claim being commenced.
Once the Insurer has admitted liability for the accident, they must pay for your ‘reasonable and appropriate’ treatment and rehabilitation costs. In deciding whether the treatment is ‘reasonable and appropriate’ the Insurer should consider a number of different factors including:
- Is the proposed treatment directly related to the injuries sustained in the accident?
- Is the proposed treatment recommended by your treating doctor or allied health provider?
- Will the proposed treatment benefit you? For example, assist in your return to work or ability to function at home.
- Is the service provider appropriately qualified and experienced and within a reasonable travel distance for you?
- Are the costs of the service reasonable?
Types of Treatment which may be Funded
Treatment expenses covered by the Insurer may include physiotherapy, occupational therapy, psychology, specialist consultations, surgery in a private hospital, radiology, medication, medical aids and equipment and, in some circumstances, domestic assistance and/or personal care.
Additionally, the CTP insurer should reimburse you for reasonable treatment expenses that you have paid for out of your own pocket.
The Process of Approval
Before the CTP Insurer will agree to pay for your treatment, they will need to see a referral from your doctor for the recommended treatment. During your first consultation with your GP you should ask for referrals for any treatment that you require.
The Insurer will take your GP’s opinion into consideration when making decisions on funding. Therefore, it is important that you regularly consult with your GP and report all of the symptoms and difficulties that you have been having since the accident.
Following the initial treatment session, Allied Health providers, such as physiotherapists and psychologists, should send a Provider Treatment Plan to the Insurer which sets out their recommendations on the number of sessions, frequency of sessions and cost of treatment.
If you have a relatively severe injury the CTP insurer may agree to fund an initial needs assessment performed by an Occupational Therapist to assess what treatment you require, how long you will require the treatment for and the costs of that treatment. These treatment recommendations will be provided in a report and may include treatment recommendations from a variety of different treatment providers, vocational retraining and aids and equipment.
Once a request for funding is made to the Insurer, the Insurer is required to respond in writing within 10 business days advising whether the requested treatment is approved, not approved, partially approved or if further information is required to consider the funding request.
If the Insurer refuses funding, they must provide you and your treatment provider with written reasons for their decision.
Reviewing the Insurer’s Decision
At times, CTP insurers will refuse funding despite recommendations made by your treating doctor and other providers. You can take steps to dispute the Insurer’s decision.
If you have engaged a lawyer to act on your behalf, your lawyer, as a first step, should ask the Insurer to reconsider their decision with reference to why the proposed treatment is ‘reasonable and appropriate’. Your lawyer may gather records or other evidence from your medical providers to support this.
If that is unsuccessful you may either:
- Apply to the Motor Accident Insurance Commission (MAIC) to appoint a mediator to help resolve the issue;
- Make an Application to the Court to decide which treatment is reasonable and appropriate in the circumstances.
Our experienced personal injury lawyers have extensive experience and success in getting Insurer’s to change their decision to refuse rehabilitation, and in applying to the Court for orders requiring the CTP Insurer to meet their funding obligations. If you require our assistance in having your right to rehabilitation met by the CTP insurer, please contact us here to arrange a free 30 minute telephone consultation.
