Category: Health Insurance

There is an inquiry into some types of legislation every Parliamentary term.
It tends to be routine. There are calls for submissions, but no publicity and usually vested interests merely state their positions.
In this case insurance for people injured in Motor Vehicles is under the Law and Justice Committee rather than the health-orientated Social Issues Committee, which shows the government’s priority; keeping the premiums down rather than actually making the insurance companies treat people fairly.
Here are the Terms of Reference- submissions are accepted until 7 October 2025.
https://www.parliament.nsw.gov.au/lcdocs/inquiries/3131/Terms%20of%20Reference%20-%202025%20Review%20of%20the%20Compulsory%20Third%20Party%20insurance%20scheme.pdf
Here is my submission to the inquiry, with suggestions as to what need to be done.

‘Transparent Competition and Fair Go for NTDs Needed in CTP’
A Submission to NSW CTP Inquiry September 2025

I very much welcome this Inquiry and would be happy to appear before your Committee to elaborate on and/or to clarify any other questions that you may have. I also have patients who would be more than willing to give evidence, some of whom would have difficulty doing this is in writing, but would be able to speak to the Committee.
I am a medical practitioner (GP) with a special interest and expertise in Workers Compensation (WC) and Compulsory Third Party (CTP) insurance since 1983. I have a current practice of at least 100 patients. Many of my patients are from socioeconomically disadvantaged or NESB backgrounds with the worst jobs and the highest injury rates.
My initial qualifications were in medicine and I am a Fellow the Royal College of Surgeons of England and have a Master’s degree in Applied Science in Occupational Health from UNSW. I had considerable experience in intensive care medicine and became active in the anti-tobacco movement because I realised that prevention was better and cheaper than cure. As an Australian Democrat MLC, 1998-2007, I initiated consequential inquiries into DOCS (now Dept. of Community Services), and Mental Health.
Thus, I understand health policy at both a political and coal-face level. The key problem is that the major unstated policy of our fragmented health system is that the main objective for each participant group, Federal government, State Governments, insurers and Patients is to minimise their costs without regard to the total cost of the system. This is especially true in the Workers Comp and CTP area. There is theoretical competition in the CTP area between insurers, but it is not real competition as consumers are not able to tell which insurers give them a better deal and are left to judge by the TV ads. What happens in practice is that the insurers delay, deny and dispute claims, so that patient will go elsewhere for treatment. Claims with ongoing problems are classified as ‘minor injuries’. This means that if treatment is delayed for 6 months, the insurers are free from further liability. The tactic is therefore to accept the claim, but deny investigations, so that the diagnosis can be disputed and treatment not initiated. Since there is no penalty for denials and disputes, the worst that can happen to insurers is they are compelled to do the treatment that they should have paid for, months or even years before, given the glacial pace of the legal system. It is likely that insurers have calculated that if a high percentage of denials are successful, even if they lose a few they are still better off financially with a ‘denial’ policy.
Insurers also produce ‘Injury Management Plans’ which might be considered farcical. They are 5 pages long on thick paper (clogging up any paper-filing system that retains them). They take absolutely no notice of the NTD’s diagnosis on the Certificates of Capacity and merely state the insurer’s medical code names for what they have accepted liability for. The IMPs then state the responsibilities of all parties as they would have them understood, with the obligations of the patients to do as they are told by the insurer, the NTDs to provide certificates and ;input’ to the Management plans, which remain the prerogative of the insurers. Their obligation to pay for ‘reasonable and necessary’ treatments seems neglected. I have had patients with very serious leg injuries after falls, who also sustained back or neck injuries in the falls. The leg injuries got all the attention in the EDs at the time, but the back injuries were what stopped them working in the medium term. Yet the insurer would not acknowledge liability for these contemporaneous injuries and maintained that they must have happened at a later date, as if this would happen as they convalesced with their legs up. The injuries may miss scrutiny because EDs concentrate on the most serious immediate problem and the strong pain killers given may mask other injuries. What needs to happen is that the insurers must either accept the diagnoses on the NTDs certificates or have it disputed through a medical panel immediately. The IMPs could be thought of as a complete waste of medical time, but NTDs are paid $100 to read and accept them (easy money) and they serve to reinforce the insurers’ right to ignore diagnoses that they may have to pay to treat later and reinforce their right to have the final say on management.
Most GPs do not dispute the denials and some Rehabilitation practitioners engaged by the insurers see the insurers as the client rather than the patient, push the patient back to work when they are not yet ready and try to bully the GPs to do the same. I have had two insurer-hired Rehab companies tell patients to change their GPs when the GPs did not do where they wanted.
The system of using Independent Medical Examiners (IMEs) by insurers has to be changed. These IMEs have a strong financial interest in coming to clinical assessments that favour insurers. Medical problems are minimised or attributed to age or other factors that were completely unnoticed until the date of the accident. Their assessments very frequently result in treatment denials or withdrawal of liability for diagnoses with consequent withdrawal of benefits. The impecunious patient then appeals to a lawyer, who arranges another IME, a dispute results and the PIC has to sort it out with yet another IME. This delay is immensely detrimental to the patient’s finances, psychological state and often their long-term outlook. A better system would be to have the insurers obliged to pay the NTDs management plan or appeal to a Medical panel. The ideal would be a medical panel chosen by the relevant college without insurer input, so that it is a medical decision what is ‘reasonable and necessary’ treatment. An alternative that might save time would be an IME agreed by both insurer and the patient’s lawyer, but most patients do not have lawyers, and obviously it is better if they do not need them.
It might be noted that the legal system redress processes are so slow that in many cases the damage is often irreparable before they even have a hearing. My disadvantaged patients are often paid in cash and have less than 3 weeks before they are unable to pay for food and rent. The time taken by insurers to approve cases and Nominated Treating Doctors (NTD) requests is extremely destructive to patients. The denial of a large percentage of treatment requests is not monitored by the State Insurance Regulatory Authority (SIRA), despite my request for them to do so, and my providing evidence to them that up to 61% of treatment requests are denied. I have had a number of patients who have been strung along with treatment denials for over 5 years; my longest who actually won was 14 years.
Delays are allowed in the NSW legislation. My own statistics for CTP, which I gave to the Hayne Royal Commission on Financial Services showed that in an unacceptably large percentage of cases treatments were denied by insurers. NRMA was the worst at 61%, Allianz at 43%, QBE 36% and Suncorp (GIO and AAMI) at 19%. Another source, which I am not at liberty to disclose, had a sample size 10 larger than mine, with similar results. These figures were from 2016, but I do not believe the situation has changed significantly. It might be noted that insurers have ‘accepted’ a very high percentage of the claims, but then refuse the treatment of these claims without this being noted or sanctioned by SIRA. It seems that SIRA functions as a senior insurance clerk to minimise payouts, but not in any way as a patient advocate. Our CTP system, which started as a means of getting top rate care motor accident victims in NSW, is now examined in terms of ‘the impact of the bill on cost and economic conditions’. It is significant that it is the hands of the Law and Justice committee rather than the any health-related committee. If our current situation is viewed merely as a cost to be minimised by the insurers, employers and NSW Government, we can only expect to see ever-declining health outcomes for my patients and our NSW community. It seems that there has been an immense influence into the systems of algorithm-generated management plans and US input so that CTP and WC systems are training and preparing for the days when insurance companies decide what treatments will be done, and doctors do what they are permitted to do by insurers. I first encountered this in 1983 when discussing treatments with American doctors at a conference. While all the non-US doctors discussed the subject in terms of optimum drugs and protocols, the US doctors talked about what they were allowed to do in terms of individual patient’s insurance schemes. It is now normal there and coming here by stealth.
The best way to save costs is to optimise treatment. Generally this means empowering GPs, who are the Nominated Treating Doctors (NTDs) actually to do their jobs without insurer delays and denials. It might be noted that GPs do not make any money from investigations or referrals. There may also be an insurer prejudice against GPs, on the assumption that if an accident were serious it would go to an Emergency Department (ED). While it is true that serious accidents usually go to EDs, whiplash injuries and back pain are very common after non-fatal accidents and the problems from these may be ongoing for years, which is presumably why insurers do not want them investigated.
It would appear from an NTD medical perspective that treatments are still denied according to either an algorithm or a protocol to save money, and these algorithms or protocols are presumably based on statistics. The point about medical practice is that every case is an individual and that probability is not certainty. Every case is individual and must be assessed on its merits. Insurer decisions must be transparent, and if they are made by a computer algorithm or protocol these must be made transparent for a medical discussion, not merely a financial one.
It must be acknowledged that the current system is immensely adversarial. The insurance clerks who are responsible for cases are somewhat pretentiously called ‘case managers’, which of course should be the role of the NTD. They are rotated frequently, and it must be asked why this is. The suspicion is that they must not be allowed to become too close to the ‘clients’, i.e. patients that they are managing. They use first names in all their correspondence, but only the first initial of their surnames, presumably so that they can remain anonymous as they refuse reasonable treatments of those who absolutely need them. . One would have thought that they would be proud to have their names on their work as all health professionals are, but in practice, this is the land of ‘deny, delay and dispute’ rather than that of Help.
The medical notes are so available as to make ‘medical confidentiality’ a farce, yet insurer records are entirely opaque, protected by ‘legal privilege’. So while the NTD have to justify any decision or even a long consultation, insurers do not have the same rules applied to them. NTDs are often not even informed of treatment denials- their correspondence is with the patient. Insurers seek to replace NTD medical management with insurance clerk management. Phone inquiries from NTDs are difficult and calls are not returned more often than not. Calls are recorded supposedly for ‘training and quality purposes’, but I have had experience where the questions asked by the case manager were clearly written by lawyer as a cross examination, so I am now reluctant to answer questions or have the conversations recorded. Interestingly most insurance clerks are unable to turn off the recording. Some offer to ‘delete it later’- clearly an unacceptable alternative. Liaison between insurers and employers also seems to be poor, communication being via rehabilitation professionals late in the case management. If the doctors’ records are to be available for perusal and judgement, then the insurers’ cases records should be similarly available for subpoena. Perhaps the reasons for unconscionable delays might be elucidated.
Two non-medical aspects are worthy of the Committee’s attention:
1. The CTP system now has some degree of wage substitution, which is a good and necessary thing. However, many students and migrant workers are paid in cash for at least part of their work. When they are injured the wage substitution only encompasses the part that was taxed. Currently employers are happy to understate incomes to keep their premiums lower and insurers are happy to accept these low numbers as it lessens their payout. The victims need to have their incomes maintained and should be assessed by what they had received, though this naturally has practical problems.
2. Police should be required to make a report in all accidents that are reported to them, and note that the accident took place, who was in the wrong and some degree of the severity of the accident. I have had people with significant whiplash injury denied compensation because the insurer considered that he dent in the bumper bar was not deep enough and have had people significantly injured where the other party denied that the accident took place at all. A person made racist slurs and deliberately ran into another car (which caused immense psychological injury).
(There is also some fraud where independent assessors hugely overstate the damage done to cars and repairers do needless repairs, sometimes buying ‘courtesy cars’ which they loan to the owners and charge the insurers exorbitant hire charges to pay off the courtesy cars. Naturally this scam affects insurers rather than my patients, but attention needs to be given to accreditation of assessors. This is a motor accident matter, but not a CTP matter. Having police attend would also make this less likely).
The solutions for the Medical management of CTP are:
1. To recognise that the problem of the CTP system is that it is a dysfunctional medical insurance system which minimises short-term treatment costs, which perpetuates the medical problems while maximising the administrative, investigative, medical reassessment and legal costs. The delays adversely affect outcomes. Improving treatment should be the first step in lessening costs;
2. To put the NTDs at the centre of the system, allowing them to organise treatments as happens with all other forms of health insurance. This needs to be mandated by law or regulation or insurers will not do it.
a. NTDs should be able to order the same investigations, referrals or treatment that are reasonable and standard in private practice, and the insurers should be obliged to pay for them as any other health insurance fund does. Appeals against this by insurers should be to a panel of doctors appointed by the specialist colleges. It might be noted that published protocols for emergency department management of cases require immensely more investigations than are suggested by GP NTDs.
b. NTDs should choose the rehabilitation professionals. If insurers feel that rehab is needed, they could suggest this to the NTDs;
c. NTDs should be notified of approvals or denials of medical investigations or treatments at the same time as the patient, and be able to comment on these and appeal the decisions.
d. NTDs should be given copies of the reports of IMEs (Independent Medical Examiners) used by either insurers or defendant or plaintiff lawyers within a week of their being received by the insurer or lawyer, and be given an opportunity either to use the opinion for the patient’s benefit, or to respond to it.
3. To have a significant treating doctor input to the management of iCare and SIRA, both at an administrative and a case management level;
4. To make SIRA collect and make public figures on treatment delays and denials from all insurers;
5. To make SIRA a true regulator that acts for patients and sanctions insurers for unreasonable decisions. Sanctions for unreasonable treatment denials should be able to be initiated by plaintiff solicitors and ruled in the Personal Injuries Tribunal to lessen treatment denials; and finally
6. To make insurer case records as transparent as medical records are, so that the basis of decisions and their timeliness and origins are transparent and accountable.
7. To make insurer algorithms transparent and vetted by specialist colleges, who may be asked to prepare their own algorithms or flow diagrams for common conditions, so that what is ‘reasonable and necessary’ will be disputed less. This must be done by Medical Colleges without insurer input, as it might be noted that the whiplash guidelines were made by a SIRA committee which had insurer input but no input from emergency physicians or neurosurgeons, the two specialties that had the most interest in the outcome.
This is a complex area and I would be willing to appear and answer any question that the Committee might have on the working of the CTP scheme and possible alternative systems.
I attach two Appendices from my submission to the Hayne Royal Commission:
First, a 2- week survey of my patients to show the extent of insurer interference in reasonable and necessary treatments (Appendix 2);
Secondly, figures for radiology and specialist referral denials by insurers (Appendix 4).


Yours sincerely,


Dr Arthur Chesterfield-Evans M.B, B.S., F.R.C.S. (Eng.), M.Appl.Sci. (OHS), M.Pol.Econ.
636 New Canterbury Rd, Hurlstone Park 2193
0419 428 019 (m)