Next steps for your merit review fact sheet
The Merit Review Service has received your application for a merit review of the insurer’s work capacity decision. This information sheet will help you understand this process.
What is a merit review?
We review your matter as if the insurer’s original decision had not been made. We consider all the relevant information available including any new information you, or the insurer, give us. Following our review, we may make binding recommendations to the insurer, based on our findings.
There are a number of possible outcomes for you following a merit review. Our findings and recommendations may result in a decision that is less beneficial for you, or it may result in the same outcome as the insurer’s decision, or it may be more beneficial to you. It is important to understand that the review may not lead to the outcome you would like.
Who conducts a merit review?
An independent decision-maker known as a Merit Reviewer conducts the review. This means that the person conducting the review has no personal interest in the outcome. The Merit Reviewer will ensure that procedural fairness is given to you during the review process, including an opportunity for you to respond to any new information.
What is the purpose of a merit review?
The Merit Reviewer is required to make a ‘correct and preferable decision’ at the time of our review. This means that if your circumstances have changed since the insurer’s original decision was made, the Merit Reviewer must consider those new circumstances and all available relevant information, including any new information. A ‘correct and preferable decision’ is a legal term used to describe the purpose of a merit review. ‘Correct’ means that it is made according to the law. ‘Preferable’ means that there may be a range of legally correct decisions, but the Merit Reviewer must settle on the best one, taking into account all the relevant information.
The insurer must lodge a reply to your application and send a copy to you and us, including a detailed and accurate list of documents relevant to the work capacity decision and internal review, including any documents supplied by you.
The insurer’s reply to you must only include copies of documents you don’t already have. When we receive the insurer’s reply, we will confirm this in writing to you both, as soon as possible, preferably within seven days.
How long does a merit review take?
We aim to complete a merit review within 30 days. Sometimes it is completed sooner, or it may take longer depending on the circumstances of your matter, particularly if we need more information from you or the insurer. To help us finalise your merit review as quickly as possible, you should respond to any requests for information related to your work capacity as soon as you can. We may complete our review of your matter at any time after you have lodged your application, so it’s important that your application includes all the information you want us to consider.
Lodging additional information
You can lodge additional information at any time during the review process. If you do we will give the insurer an opportunity to respond. Both you and the insurer must provide any information that the Merit Reviewer may reasonably require. If you want to give us new information, you must give that information to the insurer before or at the same time as you give it to us.
Can I withdraw my application?
You can withdraw your application at any time before the completion of the review. This might occur, for example, if your circumstances have changed and a merit review is no longer required, or if the insurer has made a new work capacity decision. To withdraw your application, you just need to call, email or write to us to let us know.
Notification of findings and any recommendations
When the merit review has been completed, we will write to you and the insurer to issue our decision. You will receive a written document containing the Merit Reviewer’s findings and any recommendations made to the insurer, which are binding and must be carried out by the insurer. The document will also explain the reasons for our findings and any recommendations made by the Merit Reviewer. If the findings and recommendations are different from the insurer’s work capacity decision, the insurer is required to make a new work capacity decision in line with the findings and recommendations we have made.
What if I am not satisfied with the outcome of the merit review?
Once a merit review has been completed you have the right to ask the Workers Compensation Independent Review Officer (WIRO) to review the insurer’s procedures in making the original work capacity decision.
You should make this request by completing the WIRO Application for a Procedural Review form available on the WIRO website at wiro.nsw.gov.au and sending it to WIRO within 30 days of receiving the merit review decision. For more information, contact WIRO on 13 94 76.
Where can I go to for assistance?
If you need assistance with your merit review application, you can contact the Customer Care Team on 13 10 50. If you require an interpreter, the Customer Care Team can also direct you to our Merit Review Service team, who can arrange an interpreter for you at no cost.
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Merit Review Service
Level 19, 1 Oxford Street
Darlinghurst NSW 2010
DX: DX 10 Sydney
Phone: 13 10 50
© WorkCover NSW
Catalogue No. WC01793