Understanding the PIC’s Role in CTP Disputes in NSW
A threshold injury under the Motor Accident Injuries Act 2017 (NSW) includes a soft tissue injury and a psychological or psychiatric injury that is not a recognised psychiatric illness (adjustment disorder and acute stress disorder are the usual examples; s 1.6 and Motor Accident Guidelines Part 5).
The Personal Injury Claims (PIC) section of the State Insurance Regulatory Authority (SIRA) manages disputes under the Motor Accident Injuries Act 2017 (MAIA) in New South Wales. When a claimant disagrees with a decision made by their insurer or SIRA regarding statutory benefits, the PIC may be involved in resolving the dispute. In Greater Sydney, the PIC expects claimants to provide clear, factual and well-documented evidence to support their position. This includes medical reports, treatment records, income evidence and details of the accident. The PIC does not make decisions based on emotion or anecdote but on the legal framework of the MAIA and the Motor Accident Injuries Regulation 2017.
What the PIC Expects in Dispute Resolution
The PIC expects claimants to demonstrate that their injuries meet the criteria under the MAIA, particularly the threshold for claiming damages. This means showing that injuries are more than minor, and that they have caused a permanent impairment or a significant and permanent loss of function. The PIC will assess whether the claimant has met the threshold injury definition, including whether any neurological signs are present, such as a spinal nerve-root injury with signs other than radiculopathy. The PIC also expects claimants to have followed the Motor Accident Injuries Guidelines, which set out the standard for medical assessment and treatment.
If a claimant is disputing a decision about weekly income payments, treatment and care benefits, or damages, the PIC will expect a formal written submission. This must include a summary of the facts, a reference to relevant sections of the MAIA, and copies of all supporting evidence. The PIC does not accept informal complaints or verbal submissions as valid grounds for review.
Evidence That Matters in a PIC Dispute
The most critical evidence in a PIC dispute includes:
- A detailed medical report from a treating medical practitioner, including assessment of whole person impairment (WPI) and functional capacity.
- A report from an independent medical assessor, if required, to assess whether the injury meets the threshold for damages.
- Records of treatment received, including dates, procedures, and outcomes.
- Proof of income loss, including payslips, tax returns, or a letter from an employer.
- A completed accident report, including witness details and photographs of the scene or vehicle damage.
The PIC will not accept evidence that is incomplete, inconsistent, or not contemporaneously recorded. For example, a medical report written months after the accident without reference to earlier treatment notes may not be given full weight.
How the PIC Interprets the Motor Accident Injuries Act 2017
Under the MAIA, statutory benefits such as treatment and care, weekly income payments, and damages are not automatic. The PIC interprets the Act to determine whether a claimant is entitled to a benefit based on the facts and evidence. For example, if a claimant’s only injuries are threshold injuries, the law limits weekly benefits and treatment and care benefits after 52 weeks, as provided under section 4.4 of the MAIA. The PIC will not extend benefits beyond this point unless there is evidence of a change in condition or a new injury.
The PIC also considers whether the claimant contributed to the accident. If the claimant was partly at fault, the PIC may reduce benefits under the principle of contributory fault. However, the PIC will not reduce benefits if the claimant was not negligent, and the insurer has not established a basis for fault.
Practical Steps to Resolve a Dispute with the PIC
If a dispute arises, the claimant must first request an internal review from their insurer. If the insurer upholds its original decision, the claimant may then apply to the PIC for review. The PIC will not accept a dispute unless the claimant has exhausted internal review options.
The claimant must submit a formal dispute application within 12 months of the insurer’s decision, unless an extension is granted. The application must include all evidence listed above. The PIC will assess the application and may request further information. The claimant must respond within the timeframe specified.
If the PIC upholds the insurer’s decision, the claimant may apply to the Personal Injury Commission (PIC) for a review of the medical assessment. This process is separate from the initial dispute and focuses on the medical evidence. The claimant must provide a new medical report from a specialist to support the review.
Time Limits and When to Seek Advice
Time limits are critical. A claimant must apply to the PIC within 12 months of the insurer’s decision, or risk losing the right to dispute. The PIC does not have discretion to extend this period unless there are exceptional circumstances.
A claimant should seek independent advice before submitting a dispute. The PIC does not provide legal advice, and a claimant who proceeds without understanding the legal requirements may not succeed. The PIC’s decision is not final. If a claimant disagrees with the PIC’s review, they may apply to the NSW Civil and Administrative Tribunal (NCAT) for a hearing.
Hypothetical Example: A Claimant’s Experience in Greater Sydney
A 38-year-old office worker in Sydney’s inner west was involved in a motor vehicle accident in June 2024. They sustained a neck injury and were diagnosed with a spinal nerve-root injury. The insurer initially approved treatment and care benefits but refused weekly income payments after 52 weeks, citing that the claimant’s only injuries were threshold injuries. The claimant disputed this, submitting a medical report from a neurologist showing ongoing neurological signs and a functional capacity assessment indicating a 15% WPI. The PIC reviewed the evidence and confirmed that the claimant had met the threshold for damages and was entitled to continued benefits. The PIC also directed the insurer to reconsider the weekly payments.
Next Steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.