Match the problem to the process
Should I make a complaint, request internal review or apply to PIC?
Use a complaint for service or conduct concerns, and a statutory review process to change a claim decision
A complaint can address communication, delay, conduct or service, but it does not ordinarily replace the process for changing a reviewable insurer decision. Internal review asks a different insurer decision-maker to reconsider a specified decision. The Personal Injury Commission deals with defined medical, merit, miscellaneous and damages disputes. Read the insurer’s reasons, identify the exact outcome sought and protect the applicable review period even if a complaint is also made.
One claim can involve both poor service and a wrong decision. For example, repeated unanswered calls may support a complaint, while a PAWE calculation requires internal review and possibly merit review. Filing only the complaint may leave the calculation unchanged.
PIC is not a single general appeal form. Treatment and threshold-injury issues usually enter medical assessment, PAWE and certain benefit calculations enter merit review, fault and other listed issues may enter miscellaneous assessment, and damages claims have separate procedures. The application should be tailored to the statutory issue.
Reviewed by Herman Chan, Stephen Young Lawyers
When is a complaint the appropriate step?
A complaint can be appropriate where the concern is delayed communication, inaccessible service, repeated failure to explain, conduct or alleged non-compliance. Start with the insurer’s complaint process where appropriate and use the current SIRA claims-assistance or complaint channel for scheme help. Keep the complaint factual and identify the practical response sought.
A complaint body may help with service or regulatory concerns but may not have power to replace the insurer’s statutory decision. Ask expressly whether a separate internal review or PIC application is required and do not allow complaint correspondence to obscure that date.
What does internal review do?
Internal review asks the insurer to reconsider a specified reviewable decision, generally through a person not involved in the original decision. The request should identify the decision, alternative outcome, error alleged and supporting evidence. It is not a general request to “review the whole claim”.
The result may be required before a merit or medical dispute can proceed to PIC, subject to the particular statutory exceptions. Keep the request, lodgment receipt, acceptance or refusal and internal-review certificate.
Which PIC dispute type matches the issue?
Medical assessment covers listed medical questions such as threshold injury, permanent impairment, treatment reasonableness/necessity and accident causation. Merit review covers listed administrative decisions such as PAWE. Miscellaneous assessment covers listed liability and scheme questions. Claims assessment concerns damages disputes.
The Commission assigns matters to the authorised process, but the claimant still needs to identify the issue, decision sought and relevant evidence. Combining unrelated complaints, medical issues and calculations into one narrative can make the real dispute harder to determine.
Practical next steps
How to choose the next process
Classify the problem before completing a complaint or application.
Read the decision and reasons
Identify each statutory issue, date, supporting document and review information.
Separate service from outcome
List communication or conduct concerns separately from the decision that needs to change.
Name the alternative outcome
State the PAWE, treatment, fault, threshold, WPI or other decision sought.
Use the authorised process
Complete the insurer internal review, PIC Pathway application or complaint channel applicable to that issue.
Track parallel dates
Keep complaint, internal-review and Commission correspondence in separate chronology entries.
Evidence
Process-selection checklist
The documents should reveal both the problem and the body with power to decide it.
- Insurer decision, reasons and review notice.
- Claim number and dated communication history.
- Internal-review request and outcome or refusal.
- Complaint and response, kept separately from review material.
- Medical evidence for treatment, causation, threshold or WPI issues.
- Earnings and calculation evidence for PAWE or weekly benefits.
- Accident and witness evidence for fault or liability issues.
- PIC application, reply, directions and lodgment receipt.
Process errors to avoid
- A complaint about service does not ordinarily replace a statutory review of the decision outcome.
- Internal review is not the same as an insurer simply reconsidering an email informally.
- PIC is not one universal appeal pathway; medical, merit, miscellaneous and damages matters differ.
- Do not lodge the same undifferentiated bundle in every process.
- Do not assume a complaint, negotiation or request for reasons extends a review period.
Timing
Protect the decision-specific date while complaining
Service complaints and statutory disputes can proceed on different clocks.
- Keep the date each insurer decision and internal-review outcome was received.
- Current PIC merit-review guidance gives 28-day significance to internal-review requests and Commission applications; medical and other streams must be checked separately.
- A complaint should be made promptly, but it should not delay a required internal review or PIC application.
- Contacting SIRA, PIC, the insurer or a lawyer does not itself extend a statutory period.
Frequently asked questions
- Can SIRA overturn the insurer’s decision through a complaint?
- Do not assume so. Complaints can address assistance, conduct or compliance, while a reviewable decision usually requires its statutory internal-review or PIC process.
- Do I need internal review before PIC?
- Often, but not always. The prerequisite depends on whether the dispute is merit, medical, miscellaneous or another type and on any statutory exception.
- Is treatment refusal a merit review?
- Treatment reasonableness, necessity and causation are generally medical-assessment matters after the required internal-review step, subject to the current rules.
- Is PAWE a medical dispute?
- No. PAWE is generally a merit-review matter. Work-capacity evidence may be medical, but the statutory decision type controls the route.
- Can I make a complaint and review request together?
- Potentially, if there are both service and decision issues. Keep them separate and meet each process requirement.
- What if the insurer letter contains several decisions?
- Classify each issue and protect each applicable process. One letter can require more than one internal-review or PIC stream.
Related NSW CTP guides
Official sources
- Motor Accident Injuries Act 2017 (NSW), current in-force version
- Motor Accident Injuries Regulation 2017 (NSW), current in-force version
- SIRA Motor Accident Guidelines, current published version
- SIRA: claims assistance, enquiries and complaints
- SIRA: resolving a motor crash compensation dispute
- Personal Injury Commission: NSW motor accident disputes
- Personal Injury Commission: merit review disputes
- Personal Injury Commission: medical disputes
- Personal Injury Commission: miscellaneous claims assessment
The legislation and official guidance linked above are the public-source basis for this page. Settlement, recovery and review consequences depend on the particular claim, documents and current law.
Dispute-process review
Are you unsure which process can change the insurer’s decision?
Send the complete decision and any complaint or review correspondence. We can identify the medical, merit, miscellaneous or damages issue and the documents needed for the next step.
General information only: This page provides general NSW CTP information, not legal, financial, tax, Medicare, Centrelink or judicial-review advice. It does not determine an individual entitlement, guarantee acceptance of a late application or extend any deadline.