Understanding the PIC merit review process in regional NSW
If you have been involved in a motor accident in regional NSW and your claim for compensation has been disputed by the insurer, you may be required to undergo a medical assessment as part of a Personal Injury Commission (PIC) merit review. This process is used when a claim for motor accident injury compensation is rejected or limited by the insurer, and the claimant seeks a review of the insurer’s decision. In regional NSW, access to medical specialists and assessment services can be more limited than in metropolitan areas, which may affect the timing and availability of assessments.
The review is conducted under the Motor Accident Injuries Act 2017 (NSW), which governs all CTP claims in New South Wales. The insurer must provide a written decision explaining why benefits were denied or restricted. If you disagree with that decision, you may request a merit review through the Personal Injury Commission (PIC). This review is not a new claim, but a formal challenge to the insurer’s assessment of your injury and entitlements.
What to expect during a medical assessment in a PIC merit review
A medical assessment is a key part of a PIC merit review. It is conducted by a medical practitioner approved by the Commission to assess the nature, extent, and impact of your injuries. The assessment will focus on whether your injuries meet the threshold for damages under the Motor Accident Injuries Act 2017, and whether you are entitled to weekly income payments, treatment and care benefits, or damages.
In regional NSW, assessments may be conducted by a specialist who travels to a regional centre, or via telehealth if approved. You must attend the assessment in person unless the PIC has approved an alternative arrangement. The medical practitioner will review your medical records, ask questions about your symptoms and daily functioning, and may perform a physical examination. You are not required to have a lawyer present, but you may bring a support person.
Practical steps to prepare for your medical assessment
To ensure your assessment is as effective as possible, follow these steps:
- Gather and organise all medical records related to your injury, including reports from your treating medical practitioner, specialist referrals, imaging results (X-rays, MRIs), and any treatment notes.
- Keep a daily diary of your symptoms, pain levels, and how your injury affects your ability to work, perform household tasks, or participate in social activities. This can help demonstrate the impact of your injury.
- Confirm the date, time, and location of your assessment. If you are in a remote area, confirm whether travel assistance or accommodation support is available through the PIC.
- Bring a list of questions you would like to ask the medical practitioner, such as how your injury affects your long-term prognosis or whether you may qualify for a higher level of benefits.
- Do not alter or fabricate any medical evidence. The PIC may review your records for consistency, and providing false information can result in a claim being denied or delayed.
Common pitfalls to avoid
Several issues commonly arise during medical assessments in regional CTP claims. Avoid these pitfalls:
- Assuming that a diagnosis alone proves entitlement to damages. The law requires that injuries must meet a threshold, such as a permanent impairment of 10% or more, or a threshold injury (e.g. a soft tissue injury with specified neurological signs).
- Failing to report all symptoms, even if they seem minor. The medical practitioner will assess your overall functional capacity, not just your most severe symptoms.
- Not disclosing prior injuries or conditions that may affect the assessment. Full disclosure is required to ensure the assessment is accurate.
- Missing the assessment without notifying the PIC. Failure to attend may result in your claim being dismissed or delayed.
Time limits and dispute pathways
There are strict time limits for challenging an insurer’s decision. You must request a merit review within 6 months of receiving the insurer’s written decision. If you miss this deadline, you may still apply for a review, but the PIC has discretion to accept or refuse late applications.
After the medical assessment, the PIC will issue a determination. This may uphold, vary, or overturn the insurer’s original decision. If you disagree with the PIC’s determination, you may apply to the NSW Civil and Administrative Tribunal (NCAT) for a review. However, this is not automatic and must be based on a legal or procedural error.
When to seek independent advice
The PIC process is not a substitute for legal advice. While the Commission provides guidance, it does not represent you. If your injury is complex, you have a history of similar injuries, or you believe the insurer’s decision is incorrect, it is advisable to seek advice from a solicitor experienced in motor accident claims in regional NSW.
A solicitor can help you prepare for the assessment, review your medical evidence, and ensure your rights under the Motor Accident Injuries Act 2017 are protected. They can also assist with appeals or applications to NCAT if necessary.
Hypothetical example
A 42-year-old farmer in Wagga Wagga was involved in a motor accident in April 2025. He sustained a soft tissue injury to his neck and back. His insurer initially denied weekly payments on the basis that his injuries were not permanent or severe enough to meet the threshold. He requested a PIC merit review. The PIC arranged a medical assessment with a specialist in regional NSW. The claimant brought a diary showing he had been unable to operate farm machinery for over 12 weeks, and provided MRI results showing a disc bulge with nerve root compression. The medical practitioner concluded that his injury met the threshold for damages under the Motor Accident Injuries Act 2017. The PIC upheld the claim for damages and weekly payments.
Next steps
Every claim depends on its own facts. To request contact about your circumstances, complete the quick, no obligation enquiry form.