Understanding PIC Merit Reviews in NSW CTP Claims
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).
A Personal Injury Commission (PIC) merit review is a formal process to challenge a decision made by a Compulsory Third Party (CTP) insurer regarding a motor accident claim. In Greater Sydney, claimants who believe their ability to return to daily activities has been inaccurately assessed may apply for a merit review. This process is governed by the Motor Accident Injuries Act 2017 (MAIA) and administered by the State Insurance Regulatory Authority (SIRA). The review assesses whether the insurer's decision, such as the level of weekly income payments, treatment and care benefits, or the determination of whole person impairment, was correct under the law and supported by evidence.
How SIRA Assesses Ability to Return to Daily Activities
SIRA evaluates a claimant’s capacity to return to daily activities based on medical evidence and functional capacity. The assessment focuses on the impact of injuries on everyday tasks such as cooking, cleaning, managing personal care, driving, and participating in social or family activities. The Motor Accident Injuries Regulation 2017 and the Motor Accident Guidelines set out the framework for determining functional capacity. A claimant’s ability to perform these activities is not assessed in isolation but in relation to the nature, severity, and duration of injuries, including any threshold injuries.
The assessment considers whether injuries have caused a permanent or long-term reduction in functional capacity. For example, if a claimant reports difficulty standing for more than 10 minutes or lifting items over 5 kilograms, this may be relevant to their capacity to return to daily activities. SIRA does not assess subjective feelings of fatigue or pain alone; it relies on objective clinical findings and functional testing conducted by medical practitioners.
Evidence That Supports a Merit Review Application
To successfully challenge a decision on returning to daily activities, claimants must provide evidence that demonstrates a gap between the insurer’s assessment and their actual functional capacity. Key evidence includes:
- Detailed medical reports from treating practitioners, including assessments of movement, strength, and pain levels.
- Records of rehabilitation or therapy, including progress notes and functional assessments.
- A diary or log of daily activities, noting limitations experienced on a regular basis.
- Witness statements from family members or close associates describing changes in the claimant’s daily routine.
- Documentation of any ongoing treatment, such as physiotherapy, pain management, or psychological support.
SIRA may also request an independent medical assessment to clarify functional capacity. This assessment is conducted by a qualified medical practitioner approved by SIRA and is not influenced by the claimant’s insurer.
Time Limits and the Merit Review Process
A claimant must apply for a PIC merit review within 60 days of receiving the insurer’s decision. This deadline is strict and cannot be extended unless there are exceptional circumstances. The application must be submitted through the SIRA online portal or by post, using the official form available on the SIRA website.
Once submitted, SIRA will acknowledge receipt and assign a case number. The review process typically takes between 30 and 90 days, depending on the complexity of the case and the need for additional medical evidence. During this time, the claimant may continue to receive benefits under the original decision unless a variation is requested and approved.
If the review results in a decision that upholds or changes the insurer’s original position, the claimant may request a review of the review, or in some cases, apply to the Civil and Administrative Tribunal (NCAT) for a merits review of the PIC decision.
Common Reasons for Challenging Daily Activity Assessments
A claimant may challenge a decision on returning to daily activities if:
- The insurer has not recognised a significant reduction in functional capacity due to injury.
- The claimant’s daily activities have deteriorated since the initial assessment, despite ongoing treatment.
- The insurer has failed to consider the cumulative impact of multiple injuries, such as a back injury and a shoulder injury, on daily tasks.
- The claimant has been assessed as having a threshold injury but continues to experience functional limitations that affect daily life.
SIRA’s role is to determine whether the insurer’s decision was legally correct and supported by evidence, not to reassess medical opinions in isolation. The outcome depends on the strength and consistency of the evidence provided.
Hypothetical Example: A Case from Greater Sydney
A 42-year-old driver in Sydney’s inner west was involved in a rear-end collision in June 2025. The claimant sustained a whiplash injury and a minor spinal nerve-root injury. The CTP insurer initially approved weekly payments and treatment benefits but later declined to extend weekly payments beyond 52 weeks, stating that the claimant had returned to normal daily activities. The claimant reported ongoing difficulty with driving, household chores, and attending family events, and provided medical records showing persistent neck pain and reduced range of motion.
The claimant applied for a PIC merit review, submitting a diary of daily limitations, a physiotherapist’s report, and a specialist neurologist’s assessment confirming ongoing neurological signs. SIRA reviewed the evidence and found that the insurer had not properly considered the functional impact of the spinal nerve-root injury. The review resulted in an extension of weekly payments and a reassessment of whole person impairment.
When to Seek Independent Advice
A PIC merit review is a complex process that requires careful documentation and understanding of SIRA’s procedures. Claimants who are uncertain about the strength of their evidence, the timing of their application, or the potential outcomes may benefit from independent legal or claims assistance. However, SIRA does not provide legal advice, and any advice received should be from a qualified professional.
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.