PIC Merit Review Process for CTP Claims 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).
If you believe a decision about your Compulsory Third Party (CTP) motor accident claim is incorrect, you may be able to challenge it through a PIC merit review. This process allows injured road users to dispute decisions about benefits, injury assessments, or claim outcomes under NSW law. The Personal Injury Commission (PIC) oversees these reviews, ensuring claims align with the Motor Accident Injuries Act 2017 and SIRA guidelines.
Key Dispute Resolution Options
Under NSW law, three main pathways exist for resolving CTP claim disputes:
- Internal review by the PIC: The PIC may reassess a claim if new evidence emerges or if the original decision appears to have errors.
- Independent medical review: For disputes about injury severity or treatment, a medical expert appointed by the PIC evaluates the evidence.
- Court application: In limited circumstances, a claimant may seek judicial review of a PIC decision, though this is rare and requires specific legal grounds.
How SIRA Guidelines Apply
SIRA’s Motor Accident Guidelines provide the framework for assessing injuries and benefits. During a merit review, the PIC must consider:
- Whether the injury meets the 'threshold injury' definition under the Motor Accident Injuries Act 2017.
- Whether the claimant’s injuries align with the clinical signs outlined in the guidelines.
- Whether benefits like weekly payments or treatment costs are appropriately calculated.
Practical Steps for Disputes
To challenge a CTP claim decision, you must:
- Submit a written request for a merit review within 28 days of the PIC’s decision (or 56 days if you received a copy of the decision after the deadline).
- Provide evidence such as medical records, accident reports, and any new information that supports your case.
- Attend a review hearing if requested, where you can present your case to a PIC officer.
Time Limits and When to Seek Advice
Time is critical. Most disputes must be resolved within 28 days of the PIC’s decision. If you miss this deadline, you may lose the right to challenge the outcome. Seek legal advice immediately if:
- You disagree with the PIC’s injury assessment.
- You believe the claim was denied unfairly.
- You need help gathering evidence like medical reports or accident documentation.
Example Scenario
Consider a cyclist who received a 'threshold injury' assessment but believes their injury is more severe. They can request a merit review to challenge the assessment, providing new medical evidence showing prolonged pain or functional limitations. The PIC will then reassess the injury under the guidelines.
Next Steps
CTP claim disputes depend on the accident date, injury type, and evidence gathered. To request a free, no-obligation review of your circumstances, complete the quick, no obligation enquiry form.