One of the least understood parts of Queensland's CTP scheme is that the insurer's role starts long before settlement. From the point it admits liability, the insurer is required to fund your rehabilitation. When an insurer declines a course of physiotherapy, a psychologist, a surgical opinion or equipment that your treating doctor has recommended, that is a decision that can be questioned, and often should be.

Key points

  • Once liability is admitted, the CTP insurer must fund reasonable and appropriate rehabilitation under section 51 of the Act.
  • A refusal can be challenged with a reasoned request from your treating practitioner, through MAIC, and in the claim itself.
  • Keep treating if you can; a gap in treatment is used against the claim, and the cost is recoverable.

The obligation

Section 51 of the Motor Accident Insurance Act requires an insurer that has admitted liability, wholly or in part, to make reasonable and appropriate rehabilitation services available to the claimant. The insurer can also fund rehabilitation before liability is decided, and MAIC encourages it. The cost of rehabilitation funded by the insurer is not later deducted from your compensation.

The Act also obliges the claimant to cooperate: to attend treatment, to take reasonable steps to recover, and to attend medical examinations arranged by the insurer. Refusing reasonable treatment can reduce the compensation ultimately awarded.

What "reasonable and appropriate" means

The test is whether the treatment is reasonable for the injury and appropriate to the person, judged on medical evidence. A treating doctor's recommendation carries weight but is not conclusive; an insurer may seek its own medical opinion. What the insurer cannot do is refuse on cost alone, or delay a decision indefinitely.

Common refusals

  • Physiotherapy beyond an initial block of sessions, on the basis that further sessions are "maintenance".
  • Psychological treatment where the insurer says the condition is not accident-related.
  • A specialist referral or investigation (MRI, surgical opinion) the insurer considers premature.
  • Home help, equipment or travel costs.

Challenging a refusal

First, ask for the refusal in writing with reasons, and for the medical opinion it relies on. Second, get your treating practitioner to address those reasons directly: why the treatment is needed, what it is expected to achieve, and for how long. A specific, reasoned request is much harder to refuse than a general one. Third, if the insurer maintains the refusal, the dispute can be raised with MAIC, which regulates insurers' claims handling against published Claims Management Standards, and it can be pursued as part of the claim itself, where treatment wrongly refused becomes a head of damage recovered at settlement.

Treatment before liability is admitted

Insurers have up to six months to respond on liability, and treatment cannot wait that long. In the meantime treatment can run through Medicare, a private health fund or your own resources, and the cost is recovered in the claim. Many insurers will fund early treatment without admitting liability, and it is always worth asking.

The practical point

Keep treating. Do not stop physiotherapy because the insurer has stopped paying for it, if you can possibly continue; the gap in treatment will be used against the claim, and the cost is recoverable. And tell your lawyer the day a refusal arrives, not at the conference.

Frequently asked questions

Does the CTP insurer have to pay for my physio? Where liability is admitted and the treatment is reasonable and appropriate for the injury, yes. Ask for any refusal in writing with the medical opinion it relies on.

Can I get treatment before the insurer admits liability? Yes, through Medicare, private health or your own funds, and the cost is recovered in the claim. Many insurers will fund early treatment without admitting liability if asked.

Who regulates CTP insurers in Queensland? The Motor Accident Insurance Commission (MAIC), which publishes Claims Management Standards insurers must follow and handles complaints about claims handling.

Sources

  • Motor Accident Insurance Act 1994 (Qld), ss 45 (claimant's duty to cooperate), 46A (medical examinations), 51 (insurer's obligation to provide rehabilitation) — legislation.qld.gov.au
  • Motor Accident Insurance Commission, Claims Management Standards — maic.qld.gov.au
  • Motor Accident Insurance Commission, Rehabilitation — maic.qld.gov.au