Overview
How this affects your claim in practice
Obtain the written refusal and identify whether the insurer disputes work connection, reasonable necessity, prior approval, provider or fee rules, verification, or the section 59A period. A referral or diagnosis alone may not answer those different grounds. Ask the treating practitioner for a focused report addressing the actual objection and use the review or PIC pathway that matches the decision.
- Ask for the written decision, statutory basis and all medical material relied upon.
- At 20 July 2026, the section 60 test remains “reasonably necessary”; the future “reasonable and necessary” test begins for new treatment claims on 1 October 2026.
- Prior approval is generally required, but limited statutory and Guidelines exemptions may apply.
- A referral or diagnosis alone may not answer causation, alternatives, expected benefit, provider, fee or time-limit objections.
- There is no universal worker deadline or fixed timetable for overturning every treatment denial. Check the notice and current procedure.
- Internal review may be requested, but it is not a universal mandatory step before every treatment dispute reaches PIC.
Practical review
What to check in this situation
- Identify the exact service, provider, frequency, duration, cost and statutory reason refused.
- Check the current section 60 test, prior-approval rule and any narrow Guidelines exemption.
- Separate liability for the condition from necessity of the proposed treatment.
Records that may help
Keep the request, referral, quote, clinical rationale, insurer notice, relied-on IME and treatment history.
Next procedural step
If the insurer has failed to determine the request, document receipt and address that delay separately from the merits.
Start with the written refusal
Do not answer a treatment denial only by saying the treating doctor knows best or that the treatment is urgent. Identify every disputed proposition and the evidence used by the insurer. A section 78 notice should set out the decision and reasons; a failure-to-determine issue may need to be handled differently.
- What exact service, provider, frequency, duration and cost was requested?
- Does the insurer dispute the work injury, the diagnosis or a consequential condition?
- Is the refusal based on necessity, prior approval, provider qualification, fee, verification or section 59A?
- Does the insurer rely on an IME, file review, surveillance, treatment history or a closer/cheaper alternative?
- Has the insurer addressed the current test and the correct claim date?
Common refusal grounds and the evidence they call for
| Refusal ground | Evidence that may answer the issue |
|---|---|
| Not caused by the work injury | Contemporaneous history, accepted-injury documents and medical reasoning addressing competing causes and chronology. |
| Not reasonably necessary | Findings, treatment response, alternatives, expected benefit, risks, cost and measurable goals. |
| No prior approval | Written approval records or the exact section 60/Guidelines exemption, timing and conditions. |
| Provider or fee problem | Qualifications, SIRA approval where required, current fee-order compliance, codes, quote and itemised invoice. |
| Section 59A period ended | Claim date, weekly-payment history, WPI category and evidence of any aid, modification, high-needs or secondary-surgery exception. |
| Insufficient verification | Referral, appointment or service record, itemised account, receipts and proof the expense was incurred. |
Ask the treating practitioner to address the disputed question
A short report directed to the insurer’s reason is often more useful than a general letter repeating the diagnosis. The practitioner should remain within their expertise and explain the clinical basis rather than advocate a legal conclusion.
- Current diagnosis and relationship to the accepted work injury.
- Relevant clinical findings, symptoms and functional restrictions.
- Treatment already tried and the response, including why it failed, ended or should continue.
- Exact proposed service and expected clinical or functional benefit.
- Alternatives considered and why this recommendation is appropriate.
- Frequency, duration, cost and review or stopping point.
- Effect on recovery at work and any certificate-of-capacity restrictions.
Check prior approval and Guidelines exemptions
Most treatment requires prior insurer approval. Part 4 of the Workers Compensation Guidelines contains limited exemptions, including initial treatment within 48 hours and specified periods or conditions for nominated treating doctors, public hospital emergency departments, specialists, imaging, pharmacy and SIRA-approved allied health.
Do not assume the exemption applies because the service was medically recommended. Match the provider, service, referral, timing, session count and any Allied Health Treatment Request to the exact Guidelines rule.
Check whether section 59A is the real issue
A clinically supported service can still be outside the section 59A compensation period. Physical injuries ordinarily have two-year or five-year periods depending on WPI, with no time limit for a worker with high needs. A primary psychological injury within the 2026 reform scheme ordinarily has a one-year period and the no-limit exception is confined to a worker with highest needs.
Specified aids and appliances, home or vehicle modifications and qualifying secondary surgery are excluded from the ordinary time limit. These exceptions do not remove the remaining section 60 requirements.
Review and Personal Injury Commission options
A worker can ask the insurer to review a treatment decision and provide new evidence. The applicable process and any response date should be checked in the notice and current SIRA material. Internal review is not a universal mandatory prerequisite for every treatment dispute.
After an insurer decision or failure to determine, a dispute about past or future medical expenses may be lodged in the Personal Injury Commission. Legal issues can be determined in the legal dispute pathway, and a medical issue may be referred to a medical assessor. The evidence is generally lodged as one indexed, paginated and non-duplicative bundle.
There is no reliable generic promise that a treatment dispute will finish in a fixed number of weeks or months. Timing depends on the issues, evidence and current Commission process.
Managing treatment while a dispute continues
Discuss clinical urgency and safe alternatives with the treating practitioner. Do not stop prescribed treatment or change medication based on a website. If paying privately, keep itemised receipts and do not assume reimbursement will follow if the dispute succeeds on another issue.
Keep certificates of capacity and treatment records current where the refusal affects work capacity or suitable duties. A gap created by the refusal should be documented so it is not later mistaken for recovery or disengagement.
Official sources
Sources are listed for transparency. This guide is general information only and is not legal advice.
- Workers Compensation Act 1987 (NSW), sections 59, 59A and 60
- Workplace Injury Management and Workers Compensation Act 1998 (NSW), sections 279 and 287A
- SIRA Workers Compensation Guidelines in force from 1 July 2026, Part 4
- SIRA Standard S15: treatment approval and payment
- SIRA: dispute resolution pathways
- Personal Injury Commission: medical dispute pathways
Frequently asked questions
Can an insurer refuse treatment recommended by my doctor?
Yes, an insurer can dispute payment. The recommendation is important evidence, but the expense must satisfy the applicable injury connection, necessity, approval, section 59A, provider, fee and verification rules.
How long does the insurer have to decide a treatment request?
SIRA Standard S15 requires an insurer to determine a medical, hospital or rehabilitation approval request within 21 days under section 279. A failure to determine may open a dispute pathway; it does not itself guarantee approval.
Do I have to request an insurer review before going to PIC?
Not in every treatment dispute. Review can be useful, but whether it is required or appropriate should be checked against the decision and the current pathway. The special mandatory review rules for new relevant-conduct psychological claims should not be generalised to ordinary treatment disputes.
Can I pay privately and claim the cost later?
Possibly, but reimbursement is not assured. The service still needs to satisfy the applicable law, and prior-approval rules may matter. Keep itemised records and obtain advice before incurring substantial private costs.
What if the insurer relies on an IME?
Compare the IME’s diagnosis, assumptions and treatment reasoning with the accepted injury, treating findings, treatment response and proposed goals. Ask the treating practitioner to address specific differences rather than simply describe the IME as unfair.
Workers compensation help by location
We assist workers across NSW. Choose a location guide for contact options, appointment information and links to the claim issues discussed on this page.
- treatment dispute guidance for workers in Westmead
- workers compensation assistance in Parramatta
- treatment and IME dispute help for Newcastle workers
- claim guidance for workers on the Central Coast
Browse NSW workers compensation location guidesRead how IRO and ILARS funding is assessed
Need the treatment refusal reasons checked?
Provide the request, decision, accepted-injury documents, treating reports, section 59A history and any IME material. We can identify which issue needs evidence and which review pathway may be available.