I've been hurt in a Motor Vehicle Accident in Qld. Who pays for Rehab and Medical Treatment?

In Queensland, if you suffer an injury in a motor vehicle accident, you may be entitled to have your medical and rehabilitation expenses paid for by the Compulsory Third Party (CTP) insurer of the vehicle at-fault.

Under Section 51 of the Motor Accident Insurance Act 1994 (Qld), a Compulsory Third Party insurer can fund rehabilitation and medical expenses for an injured person through their own initiative or at the request of the injured person.

 The decision to fund rehabilitation services can be made once liability or fault has been admitted by the CTP insurer or the CTP insurer can agree to fund the rehabilitation services without making an admission of liability or fault.

 Once the decision to fund rehabilitation services has been made, the CTP insurer must ensure that reasonable and appropriate rehabilitation services are made available to the injured person.

What are Reasonable and Appropriate Rehabilitation Services?

The Motor Accident Insurance Commission have developed guidelines to assist CTP insurers with making decisions on funding reasonable and appropriate rehabilitation services and treatment.

 The types of treatment and rehabilitation services which may be funded by a CTP insurer may include but is not limited to: -

•  Surgery or hospitalisation;
• Review by or consultation with a specialist;
• GP Consultations;
• Physiotherapy, hydrotherapy, and occupational therapy;
• Payment of radiological investigations such as X-Rays, CT Scans, Ultrasounds and MRI’s;
• Psychological treatment including psychological counselling or review by a Psychiatrist;
• Pain management programs; and
• Prosthetics, medical devices, aids and home/vehicle modifications.

The type and level of treatment that an injured person will receive will depend on the injuries they have suffered in the motor vehicle accident and the opinions of their healthcare and treatment providers.  

The healthcare/treatment providers will be required to deliver a Provider Treatment Plan which sets out their assessment and diagnosis of the injuries, the limitations and functioning of the injured person, the nature of the proposed treatment and the frequency of the recommended treatment (eg. weekly physiotherapy for 8 weeks).

When considering whether the recommended treatment is reasonable and appropriate, the CTP insurer should consider the following: -

1. Is there sufficient evidence to support a direct relationship between the injury and the accident?
2. Is the proposed service appropriate for the injury?
3. Will the proposed service benefit the injured person?
4. Is the service provider appropriate?
5. Are the proposed costs reasonable?

The purpose of funding rehabilitation at an early point is to give injured people the best possible chance to recover in the long-term and assist injured people to return to work and their normal activities as soon as reasonably possible.

What happens before Funding is Approved or if a CTP Insurer refuses to Fund Treatment?

Many injured people require treatment immediately following an accident.

Before CTP funding is approved or if it is not approved by the CTP insurer, treatment may be paid through:

• Medicare (subject to future reimbursement issues in some cases);
• private health insurance (subject to future reimbursement issues in some cases);
• the individual's own funds (it is important that injured people retain receipts/tax invoices); or
• workers' compensation (if the accident occurred during the course of employment).

Once the CTP insurer has approved funding or at the settlement of the claim, an injured person may seek reimbursement for the out-of-pocket treatment expenses they have occurred.  

If an injured person is not satisfied that the CTP insurer is providing reasonable and appropriate rehabilitation services, under Section 51 (5) they can apply to the MAIC to appoint a Mediator to resolve the issue or apply to the Court to have them decide what is reasonable and appropriate. However, an application to the Court may be an expensive exercise and may also delay the progress of a claim.

How long will the Insurer pay for Rehabilitation?

There is no fixed period.

Funding generally continues while treatment remains reasonable, necessary and supported by medical evidence.

Early Legal Advice Matters.

It is important to obtain legal advice at an early stage to ensure that appropriate rehabilitation funding is pursued as soon as possible. A lawyer can:

• identify the correct CTP insurer;
• assist with lodging the claim;
• communicate with insurers regarding treatment approval;
• obtain supporting medical evidence;
• resolve disputes regarding rehabilitation funding; and
• ensure all past and future treatment expenses are properly claimed.

Early rehabilitation not only supports recovery but may also improve long-term outcome of the injuries and reduce the financial burden on injured individuals.