Key References & Legislation
Whether it's physiotherapy, specialist visits, or diagnostic scans, you have the right to challenge decisions that prevent you from getting the care you need. Insurers are legally required to fund treatment that is reasonably necessary as a result of your work injury.
What this page helps you do
If an insurer says your physio, psychology, surgery review, injections, medication, or imaging is not approved, the issue is usually not just the treatment itself. It is about evidence: whether the request is linked to the work injury, whether it is clinically justified, and whether the insurer can point to an IME or file note to resist paying. This guide shows where treatment denials usually come from and where the dispute pathways sit.
Commonly denied treatments
- Physiotherapy or chiropractic sessions: Often denied after the initial treatment block or when the insurer says progress has plateaued.
- MRI or CT scans: Insurers may refuse expensive diagnostic imaging, even when it is needed to clarify surgical, spinal, or pain-management issues.
- Psychology or counselling: Frequently challenged in stress, trauma, and secondary-psychological injury matters.
- Specialist referrals and second opinions: Insurers sometimes resist paying for independent specialist review once they already have an IME opinion they prefer.
Has your treatment been rejected?
Don't assume the insurer is right. If the treatment is related to your work injury and properly supported, there is often a real dispute path available.
Why insurers stop approving treatment
1. The “cap” myth
Insurers often suggest you have had enough sessions or reached some internal limit. In reality, the real question is whether treatment remains reasonably necessary, not whether the insurer is tired of paying.
2. Maintenance care arguments
A common denial theme is that treatment only maintains your condition rather than curing it. That is often too simplistic. Treatment that prevents deterioration, keeps pain manageable, or supports work capacity can still matter materially.
3. Relatedness and pre-existing condition disputes
The insurer may argue your symptoms are due to degeneration, age, or a previous injury rather than the work event. If that is happening, compare the medical framing in this denial with our pre-existing condition dispute guide.
4. The IME report problem
Insurers frequently rely on an Independent Medical Examiner (IME) to override the recommendation of your treating doctor. If the IME misunderstands your history, ignores key imaging, or overstates recovery, the denial can often be challenged more effectively with a targeted rebuttal.
The legal test: reasonably necessary care
Under section 60 of the Workers Compensation Act 1987, treatment disputes usually turn on whether the care is reasonably necessary because of the work injury. For a practical refusal-response timeline, see our section 60 medical expenses NSW guide. If your insurer argues your treatment rights have expired, also review our section 59A medical expenses time-limits guide.
- Clinical benefit: Is the treatment expected to reduce pain, improve function, support return to work, or prevent deterioration?
- Diagnosis and causation: Is the request clearly linked to the accepted work injury or a disputed consequential condition?
- Specialist support: Does your GP, surgeon, psychiatrist, or allied health provider clearly explain why this treatment is needed now?
- Competing evidence: Has the insurer relied on an IME, factual investigation, or selective reading of your notes to say the treatment is not justified?
Evidence that usually helps treatment disputes
- A current certificate of capacity that matches your actual symptoms and restrictions
- A concise treating-doctor letter explaining why the treatment is clinically necessary
- Updated imaging, operative reports, or specialist review if the insurer says nothing objective supports care
- Physio, psych, or pain-management notes showing benefit, setbacks, or deterioration without treatment
- Insurer letters, section 78 notices, and IME reports so the actual dispute wording can be checked
How to overturn a denial
1. Check the decision type
Did the insurer send a formal Section 78 notice? If not, they may simply be delaying or effectively refusing treatment without a proper denial letter.
2. Get a focused rebuttal
Ask the treating practitioner to answer the insurer's actual reason for refusal, not just repeat the referral. A short, specific response often carries more weight than a generic certificate.
3. Escalate the dispute properly
Many treatment disputes ultimately go through the Personal Injury Commission. If weekly payments or work capacity issues are also in play, the strategy should be coordinated rather than run in isolation.
Related treatment, dispute, and payment guides
Frequently asked questions
Can I still get treatment while the dispute is running?
If you have private health insurance or can afford to pay upfront, you can continue treatment and then seek reimbursement if the dispute is resolved in your favour.
Does the insurer have to approve an MRI?
Not automatically, but if MRI imaging is needed to diagnose, confirm, or manage your work injury, it is often capable of meeting the reasonably necessary test when properly supported.
How many physio sessions am I entitled to?
There is no simple fixed number in the legislation. The real issue is whether ongoing treatment remains clinically justified and relevant to recovery, function, or work capacity.
What should I do in the first 48 hours after a treatment denial?
Get the insurer's written reason, gather the exact treatment request and your current certificate of capacity, and ask your treating doctor to directly answer the refusal reason in writing. If a section 78 notice has been issued, track the deadline immediately and prepare escalation documents early.
Need help challenging a treatment denial?
We can assess the refusal letter, the medical evidence behind it, and whether the dispute should move quickly through the Personal Injury Commission or be coordinated with other denied entitlements.