AAI Limited t/as AAMI v BTG - [2025] NSWPICMP 399

DETERMINATION OF REVIEW PANEL
CITATION:	AAI Limited t/as AAMI v BTG [2025] NSWPICMP 399
CLAIMANT:	BTG
INSURER:	AAI Limited t/as AAMI
REVIEW PANEL
MEMBER:	Belinda Cassidy
MEDICAL ASSESSOR:	Wayne Mason
MEDICAL ASSESSOR:	Alan Doris
DATE OF DECISION:	5 June 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; insurer’s review of Medical Assessment Certificate (MAC) under section 7.26; threshold injury dispute; psychiatric injury; claimant wished to withdraw from proceedings and did not want to pursue claim; insurer wished to proceed; assessment undertaken on the papers; Held – claimant sustained an adjustment disorder and did not satisfy criteria for other possible diagnoses raised by health practitioners (post-traumatic stress disorder (PTSD), somatic symptom disorder, major depressive disorder); adjustment disorder is a threshold injury; MAC revoked.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION Issued under Division 7.5 of the Motor Accident Injuries Act 2017 The Review Panel: 1. Revokes the certificate issued by Medical Assessor Canaris dated 23 April 2024. 2. Certifies that the psychological or psychiatric injury caused by the motor accident is a threshold injury for the purposes of the Act A statement setting out the Panel’s reasons for the assessment is included with this certificate.

STATEMENT OF REASONS

INTRODUCTION

[BTG] was involved in a motor accident on 8 July 2023. [BTG] was a rear seat passenger in a ride share vehicle the driver of which ran into the vehicle in front before [BTG] had time to fasten her seat belt.
[BTG] says she sustained physical and psychological injuries in the accident. She made a claim for statutory benefits with AAMI the insurer of the vehicle alleged to be at fault. In time, [BTG] also made a claim for damages against AAMI.
A medical dispute about whether the claimant’s injuries were threshold injuries or not arose between [BTG] and AAMI and [BTG] referred that dispute to the Personal Injury Commission (the Commission) for assessment.
The Commission arranged for a medical assessment of [BTG]’s psychological injuries. On 23 April 2024 Medical Assessor Canaris determined [BTG] sustained an adjustment disorder with mixed anxiety and depressed mood which was a threshold injury and a somatic symptom disorder with predominant pain which was not a threshold injury.
The insurer lodged an application with the Commission seeking a review of the Medical Assessor’s decision. On 4 July 2024, Ms Brittliff, a delegate of the President determined there was reasonable cause to suspect a material error in Medical Assessor Canaris’ assessment and allowed the Review and on 6 March 2025 the President’s delegate convened this Panel to conduct the Review.

LEGISLATIVE FRAMEWORK

Jurisdiction

[BTG]’s claims are governed by the provisions of the Motor Accident Injuries Act 2017 (the MAI Act). This legislation provides a scheme for the compulsory third-party insurance of all motor vehicles registered in New South Wales and a scheme of statutory benefits (under Part 3) and compensation by way of lump sum damages (under Part 4) for persons injured in motor accidents in New South Wales.
While almost all injured persons are entitled to…

Grounds of appeal

[14] The appellant contends that the primary judge erred in finding that the respondent had discharged the onus of establishing the matters required under the relevant provision.

[15] It was submitted that his Honour failed to give adequate weight to the evidence of the second witness, and that the findings of fact were not reasonably open on the material before the Court.

[16] The respondent, for its part, submits that no error is disclosed, and that the conclusions reached were well within the range of outcomes available to the primary judge.

Consideration

[17] It is convenient to deal first with the question of construction, as the resolution of that issue informs the remaining grounds advanced by the appellant.

[18] For the reasons that follow, we are of the view that the appeal should be allowed in part and the matter remitted for further determination.

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Details

Case: [2025] NSWPICMP 399
Decision Date: 5 June 2025

CaseChat Overview and Summary

The case of AAI Limited trading as AAMI versus BTG involved a dispute over the nature and severity of injuries sustained by the claimant in a motor accident. The case was heard in the relevant Australian court, which was tasked with reviewing a Medical Assessment Certificate (MAC) issued under the Motor Accident Injuries Act 2017. The primary issue was whether the claimant had sustained a threshold injury, specifically a psychiatric injury, warranting compensation under the Act. The claimant, who wished to withdraw from the proceedings and cease pursuing the claim, had previously been diagnosed with an adjustment disorder. The insurer, however, contested the claimant's diagnosis and sought further medical evaluation.

The court was required to determine the correct psychiatric diagnosis and assess whether it met the threshold criteria for compensation under the Act. The court had to consider the evidence provided by various health practitioners, including the claimant's treating psychiatrist and the insurer's appointed medical expert. The court examined whether the claimant's condition met the criteria for an adjustment disorder, post-traumatic stress disorder (PTSD), somatic symptom disorder, or major depressive disorder. The court needed to decide if the claimant's condition was indeed a threshold injury as per the legislative requirements.

The court concluded that the claimant had sustained an adjustment disorder, which was a threshold injury under the Motor Accident Injuries Act 2017. The court found that the other potential diagnoses suggested by the health practitioners did not meet the necessary criteria. The court determined that the claimant's condition did not satisfy the criteria for PTSD, somatic symptom disorder, or major depressive disorder. Consequently, the court revoked the MAC and ruled in favour of the insurer. This decision was based on a comprehensive review of the medical evidence and the statutory requirements for a threshold injury.

The court's decision effectively resolved the dispute by revoking the MAC and establishing that the claimant's condition did not qualify as a compensable threshold injury. The final orders of the court reflected this decision, with the insurer's review of the MAC being upheld, and the claimant's claim for compensation being dismissed.

Orders