9.1 This Part of the Guidelines is made under section 6.1 of the Act. It sets out the requirements to transition the payment of statutory benefits for treatment and care from a licensed insurer to the Lifetime Care and Support Authority (LTCSA) as the relevant insurer.
9.2 This Part applies to licensed insurers. It also applies to LTCSA in the exercise of its functions as the relevant insurer:
(a) for the payment of statutory benefits for treatment and care provided more than 5 years after a motor accident under section 3.2 of the Act
(b) when it enters into an agreement with a licensed insurer to assume responsibility for the payment of statutory benefits for treatment and care provided within 5 years after a motor accident under section 3.45 of the Act.
9.3 This Part is in two sections to reflect the key stages of the transition process:
(a) before LTCSA is the relevant insurer
(b) after LTCSA is the relevant insurer.
9.4 The following principles apply to transitioning the payment of statutory benefits for treatment and care from a licensed insurer to LTCSA:
(a) the injured person is kept informed of what is happening
(b) the injured person is not adversely affected by the transition process
(c) the licensed insurer and LTCSA work collaboratively to ensure proactive and timely support for the injured person to optimise their recovery and return to work or other activities
(d) customer service outcomes are prioritised along with efficient and responsible decision-making, including early resolution of claims where possible, and the quick, cost-effective and just resolution of disputes
(e) the transition does not adversely affect the quality of decision-making on whether statutory benefits are payable for the cost of treatment and care
(f) complete, accurate and up-to-date information relevant to the payment of statutory benefits for treatment and care is shared openly and transparently between the licensed insurer and LTCSA to support a smooth transition.
Before LTCSA is the relevant insurer
Data and information
9.5 The licensed insurer must provide LTCSA with accurate and up-to-date data in the manner determined by the Authority, including:
(a) all claims likely to require treatment and care more than 5 years after the motor accident
(b) all claims where the injured person is receiving treatment and care more than 156 weeks after the motor accident and the only injuries resulting from the motor accident were minor injuries. For these claims, the licensed insurer must also provide the reason under section 3.28(3) of the Act that the payment for treatment and care is authorised.
9.6 The licensed insurer must provide LTCSA with copies of all data and information agreed between them to be relevant to the claim. The licensed insurer must provide the agreed data and information as early as possible.
9.7 If there is a disagreement between the licensed insurer and LTCSA about the provision of data and information that they cannot resolve, either one may refer the matter to the Authority for direction.
9.8 If LTCSA enters into an agreement with a licensed insurer to assume responsibility for the payment of statutory benefits for treatment and care during the period of 5 years after a motor accident, LTCSA and the licensed insurer must retain a copy of the executed agreement and provide it to the Authority on request.
9.9 Unless a claim is finalised and closed, a licensed insurer must give the injured person notice that LTCSA will become the relevant insurer for the payment of statutory benefits for treatment and care.
9.10 The notice must be in writing and given at the following times:
(a) if there is an early assumption of responsibility by LTCSA during the period of 5 years after the motor accident — at least 2 weeks before the likely date that LTCSA becomes the relevant insurer, or
(b) if LTCSA becomes the relevant insurer for payment of treatment and care provided more than 5 years after the date of the motor accident — 4 years and 6 months after the date of the motor accident.
9.11 The notice must clearly and simply explain:
(a) the plan to transition to LTCSA as the relevant insurer for the payment of statutory benefits for treatment and care
(b) the relevant legislative provisions for that transition
(c) the ongoing responsibilities of the licensed insurer, including payment of weekly statutory benefits and/or management of any claim for damages
(d) that LTCSA will notify the injured person in writing to confirm that it is the relevant insurer and the contact details for the LTCSA contact officer
(e) contact details for SIRA’s CTP Assist if the injured person has unresolved questions or concerns.
9.12 The licensed insurer must provide LTCSA with a copy of the notice at the same time the licensed insurer gives a copy of the notice to the injured person.
9.13 The licensed insurer must also notify the injured person’s current treatment and care service providers that LTCSA will soon be the relevant insurer. This notice must be given at least 2 weeks before LTCSA becomes the relevant insurer. This clause does not apply for a licensed insurer if the injured person is an interim participant of the Lifetime Care and Support Scheme (LTCSA is responsible for notifying treatment and care service providers in this case).
After LTCSA is the relevant insurer
Data and information
9.14 After LTCSA is the relevant insurer, the licensed insurer must continue to provide LTCSA with copies of any new data and information relevant to the claim.
9.15 The licensed insurer must provide any new data and information to LTCSA as early as practicable after the licensed insurer receives it.
Initial notification requirements
9.16 No later than 5 business days after LTCSA becomes the relevant insurer for the payment of statutory benefits for treatment and care, LTCSA must notify the injured person in writing of the following:
(a) confirmation that LTCSA is the relevant insurer for the payment of statutory benefits for treatment and care
(b) the date LTCSA became the relevant insurer for the payment of statutory benefits for treatment and care
(c) details of what LTCSA will be responsible for
(d) contact details of the LTCSA contact officer.
9.17 No later than 2 weeks after LTCSA becomes the relevant insurer for the payment of statutory benefits for treatment and care, LTCSA must notify the injured person’s current treatment and care service providers that LTCSA is the relevant insurer, and provide contact details for the LTCSA contact officer.
Ongoing notification requirements
9.18 The licensed insurer must notify LTCSA within 7 days after a damages claim is settled that is related to a claim for which LTCSA is the relevant insurer for the payment of statutory benefits for treatment and care.
9.19 LTCSA must notify the Authority of the following:
(a) disputes under section 3.45(5) of the Act that are likely to be referred to the Dispute Resolution Service (DRS)
(b) applications for judicial review, such as where LTCSA or an injured person seeks for a court to review a DRS decision
(c) any likely or actual dissolution of an agreement between a licensed insurer and LTCSA under section 3.45(2) of the Act
(d) Notifiable Data Breaches in accordance with the Privacy Amendment (Notifiable Data Breaches) Act 2017 (Cth)
(e) any funding issues identified relating to an early assumption of responsibilities by LTCSA under section 3.45 of the Act
(f) all significant breaches of any legislation relevant to the functions of LTCSA as relevant insurer under the Act.
Communication with the injured person
9.20 When communicating with an injured person, LTCSA must:
(a) communicate directly with the injured person to deal with the claim (regardless of whether the injured person is legally represented)
(b) where a friend assists the injured person with the claim – communicate directly with that friend in addition to the injured person (or, instead of the injured person if appropriate in all the circumstances), regardless of whether the injured person is legally represented
(c) if requested in writing to do so by the injured person, friend or the injured person’s legal representative, copy the injured person’s legal representative into all written correspondence
(d) in this clause: friend means a person, including a family member, who is assisting the injured person with the claim and has authority from the injured person to give and receive information about the claim. It does not include a legal representative acting on instructions. The injured person can revoke the authority at any time by notifying LTCSA or can limit the friend’s authority to a specified timeframe.
9.21 If a dispute arises between LTCSA and a legally represented injured person and is before the DRS, LTCSA is not to communicate with the injured person directly about the dispute and must communicate only with the injured person’s legal representative.
9.22 LTCSA must handle all complaints in a fair, transparent and timely manner.
9.23 LTCSA must have a documented internal complaint and review procedure and make the procedure and information on how to make a complaint readily available and accessible to all stakeholders. The procedures must refer to the rights of the customer to refer a complaint to the Authority if they are dissatisfied with LTCSA’s response to their complaint.
9.24 LTCSA must acknowledge all complaints in writing within 5 business days of their receipt. The acknowledgement must include:
(a) if LTCSA can resolve the complaint to the satisfaction of the complainant within 5 business days from the receipt of the complaint – the LTCSA’s written decision resolving the complaint
(b) if LTCSA cannot resolve a complaint to the satisfaction of the complainant within 5 days from the receipt of the complaint – a copy of the LTCSA’s complaints procedure and the contact details of the representative(s) of LTCSA handling the complaint.
9.25 LTCSA must resolve all complaints within 20 days from the date of receipt and notify the complainant in writing of:
(a) the LTCSA’s decision and the reasons for that decision
(b) the opportunity to have the complaint considered by a more senior representative of LTCSA who is independent of the original decision-maker
(c) information on the availability of external complaint or dispute resolution handling bodies (including the Authority) if the complainant is dissatisfied with the LTCSA’s decision or procedures.
9.26 LTCSA must keep a record of all complaints it receives in a complaints register and provide a summary report to the Authority every six months. This report is due within 30 days of the end of the 30 June and 31 December reporting periods. It should be formatted as set out by the Authority and include a complaints trend analysis of the risks and potential issues.
9.27 If LTCSA receives a complaint regarding the conduct of a licensed insurer, then LTCSA must:
(a) forward the complaint to the licensed insurer within 5 business days
(b) confirm with the complainant that the complaint has been forwarded.
9.28 Where the complaint concerns the conduct of both LTCSA and a licensed insurer, then the party who received the complaint must:
(a) respond to the complaint in respect of its own conduct
(b) consult with the other party as required to investigate the complaint
(c) forward the complaint to the other party for its separate response within 5 business days
(d) advise the complainant of any action taken.
Information and data provision to the Authority
9.29 LTCSA must comply with the Authority’s reasonable request to provide information or documents relevant to the payment of statutory benefits for treatment and care on a CTP claim.
9.30 If the Authority is satisfied that a document provided by LTCSA contains an error, the Authority may require LTCSA to amend the document.
9.31 LTCSA must:
(a) code the injured person’s injuries by using appropriately trained coders applying the Abbreviated Injury Scale (AIS) 2005 Revision (or as otherwise prescribed by the Authority) and claims in accordance with the Authority’s Motor Accident Insurance Regulation Injury Coding Guidelines and agreed timeframes provide up-to-date and accurate claims data to the Motor Accidents Claims Register, in accordance with the Act and the claims register coding manual, as amended from time to time, or as otherwise required by the Authority
(b) maintain consistent information on the claim file and data submitted to the claims register, and record any changes in accordance with the claims register coding manual, as amended from time to time.
9.32 LTCSA must comply with any reasonable Authority requirements for data exchange and centralised claim notification.
9.33 LTCSA must update relevant Universal Claims Database (UCD) fields in a timely manner for all claims it manages as the relevant insurer.
9.34 All injured persons must have a tailored recovery plan with the following exceptions:
(a) where the injured person is performing their pre-accident work duties
(b) where the injured person is performing their usual pre-accident activities
(c) where the claim is denied
(d) where an injured person has returned to their pre-accident work duties and other activities within 28 days of the claim being made.
9.35 Where the transition to LTCSA as the relevant insurer for the payment of statutory benefits for treatment and care happens more than 5 years after the motor accident, LTCSA must:
(a) issue the recovery plan within 3 months after the date LTCSA becomes the relevant insurer
(b) review the recovery plan where significant changes occur.
9.36 When reviewing the injured person’s recovery plan, LTCSA must consider:
(a) the nature of the injury and the likely process of recovery
(b) treatment and rehabilitation needs, including the likelihood that treatment or rehabilitation will improve earning capacity and any temporary incapacity that may result from treatment
(c) any employment engaged in by the injured person after the accident
(d) any certificate of fitness provided by the injured person
(e) the injured person’s training, skills and experience
(f) the age of the injured person
(g) accessibility of services within the injured person’s residential area.
9.37 If, following a review, LTCSA revises the injured person’s recovery plan, LTCSA must send the revised recovery plan to both the injured person and their nominated treating doctor with the following details:
(a) name of injured person
(b) claim number
(c) date of injury
(d) current treatment being undertaken
(e) future treatment expected to be undertaken
(f) current fitness for work and/or usual activities
(g) expected fitness for work and/or usual activities with milestones
(h) obligations of the injured person
(i) consequences for the injured person if they do not adhere to the recovery plan
(j) contact details of all current insurers
(k) what action the injured person can take if they disagree with the recovery plan.
Treatment and care
9.38 If LTCSA has identified an injured person requiring treatment and care, it must facilitate referral to an appropriate treatment provider (including vocational provider, if appropriate) within 10 days of the identification, with the injured person’s agreement.
9.39 LTCSA must refer the injured person to an appropriate service provider reasonably accessible to the injured person.
9.40 If the injured person expresses a preference for a particular provider, then LTCSA must refer the injured person to that provider subject to LTCSA being satisfied as to the suitability of that provider.
9.41 If the LTCSA determines that the injured person’s preferred service provider is not suitable, it must notify the injured person of the reasons for its decision and refer the injured person to another service provider reasonably accessible to the injured person.
9.42 Where LTCSA is required to determine the injured person’s request for treatment and care, it will:
(a) advise the injured person and service provider in writing as soon as possible but within 10 days of receipt of a request, and if approved
(b) state the costs LTCSA has agreed to meet
(c) pay the account as soon as possible but within 30 days of receipt of an invoice or expense.
9.43 LTCSA will advise the injured person of LTCSA’s obligation to pay all reasonable and necessary treatment and care costs and expenses – including travel expenses to attend approved treatment, rehabilitation services or assessments, including all services or assessments conducted by DRS medical assessors – as soon as possible (no later than 20 days after receiving an account or request for reimbursement).
9.44 If LTCSA is determining an injured person’s request for treatment that will potentially alter the injured person’s minor injury decision, LTCSA must contact the licensed insurer related to the claim before the decision is made and within 5 business days of receiving the request.
Claims made more than 5 years from the date of accident
9.45 For claims made more than 5 years after a motor accident, LTCSA and the licensed insurer are responsible for making decisions about the claim as follows:
(a) LTCSA — in the case of the payment of statutory benefits for treatment and care
(b) licensed insurer — for all other claim-related decisions.
9.46 The licensed insurer must make all decisions relating to the claim, except concerning the payment of statutory benefits for treatment and care. These include:
(a) whether a late claim may be made
(b) whether the injury to a person resulted from a motor accident in NSW
(c) whether the motor accident was caused wholly or mostly by the fault of the person
(d) whether the person’s only injuries resulting from the motor accident were minor injuries
(e) assessing the degree of contributory negligence.
9.47 Where the licensed insurer accepts liability for the payment of statutory benefits, LTCSA must make all decisions relating to the payment of statutory benefits for treatment and care. These include:
(a) whether expenses were incurred in connection with providing treatment and care
(b) whether the cost of specific treatment and care was reasonable and necessary in the circumstances
(c) whether the requested treatment and care relates to the injury resulting from the motor accident concerned.
Clinical dementia rating
Australasian Legal Information Institute
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Australian Bureau of Statistics
Computerized axial tomography scan
Australian Medical Association
Compulsory third party
Guides to the Evaluation of Permanent Impairment, Fourth Edition (third printing, 1995) published by the American Medical Association
Diagnostic & Statistical Manual of Mental Disorders
Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition, 2013, published by the American Psychiatric Association.
Diffusing capacity of carbon monoxide
Motor Accidents Operational Fund
Dispute Resolution Officer
Motor Accident Injuries Treatment & Care Fund
Dispute Resolution Service
Magnetic Resonance Imaging Scan
Secure document exchange box
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Electronic funds transfer
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Electronic notification of a third-party policy by an insurer to Roads & Maritime Services
Range of motion
Risk equalisation mechanism
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Forced expiratory volume
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Straight leg raising
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Measurement of exercise capacity
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Written-off vehicles register