Funding rehabilitation expenses during a CTP claim

In practice: how to get funding for rehabilitation expenses

In practice you will usually need to follow the following steps to get funding:

• The first step is usually to go to the GP and get a referral to the specialist or allied health professional who will provide the services which you require. For example, the GP may refer you to a physiotherapist.
• The physiotherapist (or other professional) then provides a quote for their services.
• You then submit the quote to the CTP insurer to get approval for funding.
• Sometimes you will need certain services (very often physiotherapy) even before you have an opportunity to arrange funding by the CTP insurer. You may need to pay for these services yourself, but you should still request the CTP insurer to reimburse these expenses as they often do. For example, you might need 10 physiotherapy sessions. You pay for the first 3 or 4 out of your own pocket which the CTP insurer then reimburses and they pay for the rest upfront.
• For significant expenses, such as surgery and hospital stays, it may be necessary to get not just a quote from the surgeon, but potentially a brief note explaining why surgery is necessary and what it might achieve.

What if the CTP insurer does not agree to fund a particular expense?

An issue which commonly arises in practice is even if the CTP insurer agrees to fund rehabilitation expenses, they don’t approve a particular treatment that you seek funding for. For example, you want surgery, but the CTP insurer denies funding.

In this situation, the CTP insurer will probably say that they do not consider the proposed treatment to be reasonable. Sometimes, they get a second opinion from a different doctor or specialist who will say that they do not agree with the recommendations of your own specialist. For example, you may have a surgeon who wants to perform surgery, but the CTP insurer gets an opinion from a different surgeon who says surgery is not warranted.

It is important to appreciate that just because doctors disagree on whether surgery is the best solution, it does not mean that your funding request is unreasonable. For the CTP insurer to deny funding, they must have evidence which explains why your funding request is unreasonable. This is important because while it is relatively common for surgeons to disagree whether surgery is preferred in a particular situation, it’s less common that a surgeon would say that a particular treatment proposal is unreasonable or inappropriate.

The Queensland Supreme Court dealt with this issue in the case of Mcintyre v AAI Limited where it was stated that “the development of treatment and rehabilitation plans is for the claimant, no doubt in consultation with his or her chosen doctors. It is the insurer’s role to facilitate the rehabilitation process which has been put in place.” And later “except to the extent that [the CTP insurer’s experts] evidence reflects up on the reasonableness or appropriateness of the rehabilitation treatment services requested, it is beside the point that those experts may have different views as to the proper ways in which [the injured person] might undertake rehabilitation.”

Ultimately, if there is disagreement between you and the CTP insurer whether a particular treatment should be funded, then you can bring an application to the Court to determine the issue. Whether it’s worth doing this depends on how much money is at stake. For example, in the recent case of Simmons v QBE Insurance, the cost of the proposed surgery was $45,000. When the CTP insurer denied funding, it was worth it for the claimant to seek court orders and ultimately, she was successful.