AAI Limited t/as AAMI v CAK

DETERMINATION OF REVIEW PANEL
CITATION:	AAI Limited t/as AAMI v CAK [2025] NSWPICMP 698
CLAIMANT:	CAK
INSURER:	AAI Limited t/as AAMI
REVIEW PANEL
MEMBER:	Terence O’Riain
MEDICAL ASSESSOR:	Ian Cameron
MEDICAL ASSESSOR:	Michael Couch
DATE OF DECISION:	11 September 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; accident 8 July 2023; treatment dispute; Medical Assessor’s (MA) certificate found causal nexus between the accident and treatment which was reasonable and necessary except for one aspect; insurer sought review on grounds that MA did not engage with insurer’s argument that forces in the accident were insufficient to cause referred injuries and the claimant was inconsistent in versions of the accident he provided to various treatment providers; insurer relied on biomechanical engineer’s expert report; claimant refused to attend re-examination; Review Panel considered treating doctors and MA’s opinions regarding nexus with accident; clinical judgment was that accident mechanism could cause referred injuries; evidence supported it being probable; appropriate treatment; section 3.24; Held – accident caused referred injuries and treatment reasonable and necessary; original certificate confirmed.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION Review Panel Assessment of Treatment and Care Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 The Review Panel affirms Medical Assessor Home’s findings in the certificate dated 3 October 2024 making the following assertions about disputed treatment and care sought under s 3.24 of the Motor Accident Injuries Act 2017: Surgery · the physical injuries giving rise to the need to excise the right tibial nerve presumed nerve [redacted] were not related to an injury caused by the accident, and · the physical injuries giving rise to a need for excision of the right tibial nerve presumed nerve [redacted] is not reasonable and necessary in the circumstances. Radiological investigations · the physical injuries giving rise to a need for the left hip MRI relates to the injury caused by the motor accident; · the physical injuries giving rise to a need for MRI of the left hip is reasonable and necessary in the circumstances; · the physical injuries giving rise to a need for the left thigh MRI relates to the injury caused by the motor accident, and · the physical injuries giving rise to a need for the left thigh is reasonable and necessary in the circumstances. *Nerve Conduction Study* · the physical injuries giving rise to a need for a nerve conduction study of the left thigh relates to the injury caused by the motor accident, and · the physical injuries giving rise to a need for nerve conduction study of the left thigh is reasonable and necessary in the circumstances. PRP Injections · the physical injuries giving rise to a need for PRP injections relates to the injury caused by the motor accident, and · the physical injuries giving rise to a need for PRP injections is reasonable and necessary in the circumstances. Medical Specialist Consultation · the physical injuries giving rise to a need for referral to hand and wrist surgeon Dr David Stewart relate to the injury caused by the motor accident, and · the physical injuries giving rise to a need for referral to hand and wrist surgeon Dr David Stewart, is reasonable and necessary in the circumstances.

REASONS

BACKGROUND

The claimant was injured in the subject accident on 8 July 2023 as the back seat passenger on the insured driver’s side of a rideshare vehicle he shared with his partner, when it collided with the rear of another rideshare vehicle.
The insurer is responsible for loss arising from the claimant’s injuries from the accident under the Motor Accidents Injuries Act 2017 (MAI Act).
The insurer and the claimant are in a dispute under s 3.24 of the MAI Act relating to the provision of treatment and care from injuries caused by the accident.
The claimant applied to the Personal Injury Commission (the Commission) to resolve this dispute.
On 3 October 2024 Medical Assessor Alan Home provided findings on treatment and care pursuant to cl 2(b) of Schedule 2 of the MAI Act certifying the claimant’s entitlement to treatment and care.
Medical Assessor Home's certificate listed the Commission's referred treatment disputes for assessment as follows:
“Surgery
1. Whether the physical injuries give rise to a need for excision of the right tibial nerve presumed nerve [redacted][1] relates to an injury caused by the motor accident.
[1] It's called "presumed" because the diagnosis is based on a combination of a patient's symptoms and the characteristic appearance of the [redacted] on an MRI, making biopsy rarely necessary.
2. Whether the physical injuries give rise to a need for excision of the right tibial nerve presumed nerve [redacted] is reasonable and necessary.
Radiological investigations
1. Whether the physical injuries give rise to a need for MRI of the left hip relates to the injury caused by the motor accident.
2. Whether the physical injuries give rise to a need for MRI of the left hip is reasonable and necessary in the circumstances.
3. Whether the physical injuries give rise to a need for MRI of the left five thigh relates to the injury caused by the motor accident.
4. Whether the physical injuries give rise to a need for MRI of the left thigh is reasonable and necessary in the circumstances.
Nerve Conduction Study
1. Whether the physical injuries give rise to a need for A nerve Conduction Study of the left thigh relates to the injury caused by the motor accident.
2. Whether the physical injuries give rise to a need for A nerve Conduction Study of the left thigh is reasonable and necessary in the circumstances.
PRP Injections
1. Whether the physical injuries give rise to a need for PRP injections[2] relates to the injury caused by the motor accident.
2. Whether the physical injuries give rise need for PRP injections is reasonable and necessary in the circumstances.
Medical Specialist Consultation
1. Whether the physical injuries give rise to a need for Referral to Dr David Stewart, Hand and Wrist Surgeon relates to the injury caused by the motor accident.
2. Whether the physical injuries give rise to a need for Referral to Dr David Stewart, Hand and Wrist Surgeon is reasonable and necessary in the circumstances.”
[2] Platelet-Rich Plasma (PRP) injections

The Medical Assessor Home found a causal nexus between all the referred injuries in the accident, except for the right tibial presumed nerve [redacted] and that all proposed treatment was reasonable and necessary.
The insurer applied for review on the basis the assessment was incorrect in a material respect, submitting that Medical Assessor Home:
(a)    failed to have proper regard to the records before him;
(b)    failed to apply the test of consistency, and
(c)    failed to provide sufficient reasons.
On 11 December 2024 the President of the Commission’s delegate constituted this Review Panel (the Panel) to review the original certificate (the Review).
The President’s delegate referred the medical assessment to the Panel as the delegate was satisfied that there was reasonable cause to suspect that the medical assessment was incorrect in a material respect having regard to the particulars set out in the application.
Clause 14F of Schedule 1 of the Personal Injury Commission Act 2020 (the PIC Act) provides that the new review provisions apply in relation to a decision of a new decision-maker. A “new decision maker” is defined in cl 14A (1) of Schedule 1 of the PIC Act. As this medical assessment was made on or after 1 March 2021, those review provisions apply.
Part 5 of the PIC Act enables the Commission to make rules with respect to the practice and procedure before the Commission including proceedings before a panel reviewing a decision of a Medical Assessor.
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (the PIC Rules) follow

Part 5 of the PIC Act. A review panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.
On 8 January 2025 this Panel wrote to the parties directing the parties to produce bundles of evidence and submissions they were relying on before the Panel was to meet on

10 February 2025 to discuss how this matter will proceed.
The insurer applied to the Commission for referral of the medical assessment to a review panel within 28 days after the medical assessment was issued.
This Panel eventually met on 11 March 2025 and directed that it would be necessary to re-examine the claimant on 13 May 2025 to assess whether the accident caused the referred injuries and the proposed treatment was reasonable and necessary following cl 2(b) of Schedule 2 of the MAI Act certifying the claimant’s entitlement to treatment and care.
The Panel noted that the insurer hotly contested that the accident mechanism could not have resulted in any injury to the claimant, and that was necessary to question the claimant on that aspect, as well as the onset of the relevant conditions.
The claimant wrote detailed submissions on 25 March 2025 on why he would not consent to re-examination, including having undergone recent shoulder surgery. He had also refused to attend examinations arranged by the insurer.
He also submitted that PIC Rule 67(b)(1) (Amendment 3) states that a review must be based on the original dispute and must not introduce an entirely new submission. He objected to the Panel treating this as a new matter, by deciding that re-examination is required instead of reviewing the original medical assessment certificate (MAC) for error — which he submits is procedurally unfair.
The insurer responded that it maintained that an examination should go ahead because the disputed treatment is unrelated to the shoulder condition, although the insurer also submitted that it would be prudent to defer the examination to allow the claimant to stabilise following his shoulder surgery.
The Panel follow up report noted the claimant’s objections to re-examination and drew the claimant’s attention to s 7.26(6) MAI Act, which obliges the Motor Accident Division’s Review Panels to perform a fresh review of all the matters with which the medical assessment is concerned. The procedure the claimant referred to is the process followed in the Commission’s Workers Compensation division.
Further, the Panel reported that while other certificates and reasons may provide probative evidence, other Medical Assessors’ or legal Members’ findings do not bind a Panel in its deliberations. The Panel is obliged to ask its own questions about the accident mechanism and examine the referred body parts to test how that could contribute to the injuries which are in issue before the Panel.
The Panel contemplated that it would be necessary to resolve this dispute on the papers, but the Panel considered re-examination was optimum to enable the Panel to make its own decision on the causation issue addressing the accident mechanism, as well as treatment.
Noting the parties’ submissions the Panel made the following directions:
(a)    the examination on 13 May 2025 was cancelled;
(b)    Medical Assessor Ian Cameron was to re-examine the claimant on 11 July 2025 on behalf the Panel at his rooms in Hornsby;
(c)    the claimant was given the opportunity by no later than 27 June 2025 to upload any documents the claimant wishes to rely on in the review proceedings not already provided, and
(d)    the insurer was to reply by 3 July 2025.
Ultimately, the claimant did not attend the re-examination. The following decision is produced on the papers.
The disputed issues presently are whether the accident caused an injury requiring the proposed procedures; whether “any treatment and care provided or to be provided to the injured person is reasonable and necessary in the circumstances or relates to the injury caused by the motor accident for the purposes of section 3.24”.

STATUTORY PROVISIONS

General

The MAI Act governs [CAK]’s claims and entitlements to benefits and compensation. The legislation provides a scheme of statutory benefits (under Part 3).
[CAK]’s statutory benefits includes weekly benefits for lost earnings and treatment and care needs for accident-related injuries.

Treatment and care benefits

The mechanism for the claimant’s recovering treatment and care costs caused by the accident is through the statutory benefits claim.
Section 3.24 of the MAI Act provides as follows:
“(1) An injured person is entitled to statutory benefits for the following expenses (treatment and care expenses) incurred in connection with providing treatment and care for the injured person -
(a) the reasonable cost of treatment and care, …
(2) No statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident concerned.”
Following Schedule 2, cl 2 of the MAI Act, treatment disputes are medical assessment matters.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act. This means that the matter is determined at first instance by a Medical Assessor, and following s 7.26 of the MAI Act, on review by a review panel (Panel) consisting of two Medical Assessors and a Member of the Commission.
Sections 5D and 5E of the Civil Liability Act 2002 (CL Act) apply to the MAI Act regarding causation. It is unclear and unlikely the provisions in Part 6 of the Motor Accident Guidelines 9.2 (the Guidelines) relating to the meaning of causation of injury and impairment apply to assessing causation in treatment disputes. This is because Part 6 specifically applies only to assessing permanent impairment.
In order to promote consistency and harmony determining medical assessment matters, the Panel proposes adopting the approach to causation set out in cls6.6 and 6.7 of the Guidelines.
“6.6 Causation is defined in the Glossary at page 316 of the AMA 4 Guides as follows:
'Causation means that a physical, chemical, or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement.
6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”
The decision in Peet v NRMA Insurance Ltd [2015] NSWSC 558 provides further guidance to the Panel on causation. Peet reviewed a number of Supreme Court decisions including the observations of Justice Campbell in Owen v Motor Accidents Authority of NSW [2012] NSWSC 560 who stated it was “well to emphasise the question to be assessed is one of legal causation involving mixed questions of fact and law arising principally from the law of negligence as modified by the Civil Liability Act, 2002, s 5D”.
Further, in Hunter v Insurance Australia Ltd [2021] NSWSC 623 the Court observed (at [16]) a Panel was obliged to apply the Guidelines which incorporated “common law principles of causation.” Under s 63(3) of the Motor Accident Compensation Act 1999 (MAC Act) Act and Sch 1, cl 14F (2) of the PIC Act, the Panel consists of two Medical Assessors and a Member of the Motor Accidents Division of the Commission.
The CL Act applies to the MAI Act in determining causation. In Raina v CIC Allianz Insurance Ltd [2021] NSWSC 13 (Raina) at [65] Campbell J stated:
“One may accept that a review Panel is engaged in a process of dispute resolution by expert assessment of medical issues arising under the Act. However, the questions arise in a legal context, and it is incumbent upon the Panel, medical practitioners they may be, to correctly apply the law including the law of causation in the exercise of their powers. This includes the provisions of Division 3 of Part 1A of the Civil Liability Act 2002 (NSW), ss 5D and 5E: see s 3B(2)(a) of that Act. Although it may be expected that questions about the appropriate scope of liability will arise but rarely.”
Wright J in Briggs No. 2 [2022] NSWSC 372 reminds the Panel that the relevant legal test in relation to causation does not require scientific certainty. His Honour stated at [70]-[72]:
“70. This reasoning does not accord with the relevant legal test in relation to causation, which does not require scientific certainty. In Metro North Hospital and Health Service v Pierce [2018] NSWCA 11, the Court of Appeal said, in relation to causation in a similar context, as follows at [138] (White JA, Macfarlan and Payne JJA agreeing):
‘138 Whether the Hospital’s negligence in not responding to the induced seizures in a timely manner materially contributed to Ms Pierce’s worsened condition is not to be determined on the basis of scientific certainty, but on the balance of probabilities. As Spigelman CJ said in Seltsam Pty Ltd v McGuiness (2000) 49 NSWLR 262; [2000] NSWCA 29 at [143]:
‘An inference of causation for purposes of the tort of negligence may well be drawn when a scientist, including an epidemiologist, would not draw such an inference’.’
71. The relevant principles were stated by Herron CJ, with whom Asprey and Holmes JJA agreed, in EMI (Australia) Ltd v Bes [1970] 2 NSWR 238 as follows, at 242:
‘... it is not incumbent upon the applicant, upon whom the onus rests, to produce evidence from medical witnesses which proves to demonstration that the applicant’s contention is correct. Medical science may say in individual cases that there is no possible connexion between the events and the death, in which case, of course, if the facts stand outside an area in which common experience can be the touchstone, then the judge cannot act as if there were a connexion. But if medical science is prepared to say that it is a possible view, then, in my opinion, the judge after examining the lay evidence may decide that it is probable. It is only when medical science denies that there is any such connexion that the judge is not entitled in such a case to act on his own intuitive reasoning. It may be, and probably is, the case that medical science will find a possibility not good enough on which to base a scientific deduction, but courts are always concerned to reach a decision on probability, and it is no answer, it seems to me that no medical witness states with certainty the very issue which the judge himself has to try.’
Furthermore, a finding of causal connection may be open without any medical evidence at all to support it, or when the expert evidence does not rise above the opinion that a causal connection is possible: Fernandez v Tubemakers of Australia Ltd [1975] 2 NSWLR 190 at 197 (Glass JA); Metro North Hospital at [140].”
These observations were made in the context of a review Panel of three medical experts unlike the present Panel’s composition following amendments to the MAC Act and MAI Act.

MEDICAL ASSESSMENT UNDER REVIEW

Medical Assessor Home issued a Medical Assessment Certificate dated 24 October 2024 (the medical assessment).
Medical Assessor Home recorded detailed notes of the parties' submissions which are summarised below.
Medical Assessor Home stated he had carefully reviewed the parties’ evidence but did not refer to Dr Michael Griffiths’ report dated 3 September 2024 on the biomechanical aspects of the accident, which was an additional document.
The claimant disputed the insurer's decision to deny the referred treatments. The claimant referred to files uploaded on the portal containing notes, medical reports, correspondence and the claimant's detailed statement.
The claimant referred to multiple specialists examining him in respect of injuries from the accident, which supported the nexus between the accident and the treatment sought.
There was a reference to the claimant acknowledging that the right tibial presumed nerve [redacted] was unrelated to the accident, but that he had support that the accident trauma exacerbated the condition, which made it necessary to excise the [redacted].
The Medical Assessor referred to adverse side-effects after the claimant underwent an insurer funded left hip injection.
The insurer declined to pay for the PRP injections in the left gluteus medius tendon because it did not relate to the accident. The insurer reasoned there was no link because there was no contemporaneous account of a left hip injury in the accident.
The insurer submitted:
(a)    the right tibial nerve presumed nerve [redacted] was not related to injuries sustained in the accident, because the relevant specialist Dr Laban did not exclusively attribute the pathology to this accident. It was an incidental finding rather than an acute injury;
(b)    the insurer submitted non-accident related causes could explain the presence of the claimant's condition;
(c)    in respect of the left hip and thigh MRI scans, the insurer mirrors the claimant's submissions. The insurer, in respect of funding the injection, says earlier claims team decisions do not bind ongoing management of a claim;
(d)    the insurer submits the left hip or thigh issues predated the accident. Dr Rooney provided a report dated 1 March 2023 regarding examining the claimant in respect of those body parts and his left foot. The claimant rebuts that submission and says Dr Rooney only examined the left knee;
(e)    the claimant's GPs notes dated 12 January 2023 corroborates Dr Rooney’s report that he was investigating hip issues. Dr Rooney reported the "left hip pain was extra articular in origin and related to the head of the rectus femoris muscle." i.e. it was not joint pain;
(f)    the MRI scan taken on 4 December 2023 did not identify any accident related acute injury, and
(g)    in respect to Dr David Stewart treating the claimant's wrists or elbows (radial tunnel syndrome) the insurer points to a lack of contemporaneous documented complaints. The insurer states it is "uncertain" how those body parts could have been injured in a low impact rear end collision. Further, there are alternative explanations for that condition arising such as overuse and asymptomatic neuropathy. The insurer refers to predisposing factors.
Relevantly, the claimant told Medical Assessor Home that his only pre-accident medical history was a back pain episode five years before this examination.
There is description of the accident, and the Medical Assessor recorded the claimant was uncertain of the accident details, but he experienced early shock symptoms. The claimant recalled he became symptomatic in the right shoulder soon after he got out of the car.
The next day he felt unwell with headache and dizziness. He saw his general practitioner Dr Rassam. The Medical Assessor recorded that the claimant's GP told the claimant he would deal with one problem at a time. Then followed the course of right shoulder investigation and treatment. Orthopaedic surgeon Dr Sushil Pant saw him for his right shoulder and also investigated his upper limbs bilaterally due to over relying on the uninjured left side.
Medical Assessor Home considered his diagnosis and view on causation. He considered the mechanism of the accident was consistent with the shoulder injury and cervical spine whiplash disorder. He noted early right shoulder complaints. He noted referral for cervical spine imaging not more than six weeks after the accident and that by September 2023 the claimant reported the right upper limb complaints and compensatory pain in the left upper limb.
Ultrasound and MRI scans diagnosed right shoulder sub- scapularis tears, mild AC degeneration, some swelling and a possible labral tear.
The referred widespread multiple physical complaints were less readily explained from the accident mechanism.
In respect of bilateral radial tunnel syndrome, the Medical Assessor could not find a plausible medical explanation with the accident. He made the same findings in respect of bilateral ulnar nerve dysfunction.
The claimant underwent a targeted injection to the anterior of his left hip, which led to an allergic reaction to the anaesthetic.
The claimant's allergy to anaesthetics makes diagnostic injections hazardous despite being able to assist assessing causation in the claimant’s circumstances
For that reason, the Medical Assessor found referring the claimant to Dr David Stewart for further upper limb investigation was reasonable and necessary, despite two upper limb specialists already examining the claimant.
The left hip pain was reported soon after the accident and continues, but the pathology is uncertain. The hip MRI scans demonstrate degenerative changes which are common and not necessarily linked to the accident. The claimant insisted he did not have left hip pain before the accident. The Medical Assessor found the accident mechanism could have caused a hip strain involving the gluteal tendons and tenderness.
On that basis the Medical Assessor found that the trial PRP injections related to the injuries caused by the accident and was reasonable and necessary.
Noting that it was hazardous to use diagnostic injections the Medical Assessor found that nerve conduction studies on MRI scanning for the thigh was related to the accident and reasonable and necessary, despite finding the presentation was atypical for a discreet peripheral nerve injury.
In respect of excising the right tibial presumed nerve [redacted], the Medical Assessor could not find a trauma related nexus with that condition.

Evidence

The claimant described the accident in his application for personal injury benefits (claim form) 18 July 2023 as follows: “
“I had requested a Didi driver from the theater located at 455 Pitt St. Once the driver arrived and picked up my partner and me, he began driving without ensuring that we had fastened our seat belts. Despite my partner’s request for assistance in locating the seat belt, the driver declined, preoccupied with a phone call. Consequently, while I was trying to help my partner secure the seat belt, the driver collided with the vehicle in front of us, resulting injuries to both of us. This incident occurred immediately after the driver had picked us up at the specified address, 455 Pitt St.”
The insurer tendered a report from Road Safety Solutions by Dr Michael Griffiths dated

3 September 2024 on the biomechanical aspects of the accident.
The report records a history that on the night the accident the claimant was the right rear passenger in a rideshare vehicle eastbound Honda Odyssey in Campbell Street in Sydney CBD.
The report notes the claimant initially reported a right shoulder injury which has extended to include a head impact causing brief loss of consciousness, an intermittent left-sided facial tic, hearing loss with tinnitus, and nerve [redacted] requiring excision, left hip, left shoulder, right wrist and elbow injuries.
The insurer instructed the expert to review the available material and report on the incident to address:
(a)    an assessment of the crash dynamics;
(b)    an assessment of the likely forces experienced by the claimant;
(c)    identifying any injury mechanism which might lead to those forces causing injury;
(d)    what injuries, if any, could the claimant have sustained in the incident;
(e)    is there any consistency between the injuries the claimant alleges and the possible injuries that could result from this incident;
(f)    what impact, if any, would the claimant’s alleged twisted posture have had on the injuries alleged in the subject accident, and
(g)    are the allegations of injury by the claimant reasonable?
The expert found:
“On the basis of the sound physical evidence of the photographs depicting the damage to both the struck vehicle and the striking vehicle, it is deduced that the 5 to 10 km/hr reduction in forward velocity for the vehicle in which the claimant was travelling was well below the threshold for injury, particularly to two occupants seated in the rear of this 2012 model vehicle. The above summary of the physical evidence is further substantiated by the descriptions of the minor severity of the incident from the driver of the not at fault vehicle struck by the vehicle in which the claimant was travelling.”
The expert relied on versions of the accident provided in telephone interviews with the insured driver and the driver of the vehicle he struck. There were also photographs which depicted shallow left side front end damage to the insured car and also shallow right side damage to the struck car’s rear bumper. The expert described these as “shallow” because the damage did not cover the full width of the bumpers.
The claimant and his fellow passenger have provided versions of the accident which refer to the insured car travelling at 50km/h. The expert disputes that speed based on his examination of the above evidence. Dr Griffiths’ view is that the damage to the vehicles would be much greater if the claimant’s recollection was correct and that it would need to be that speed for the claimant’s alleged injuries to have occurred. He also opined that the doctors supporting the nexus between the claimant’s injuries in the alleged accident were misled by the claimant’s account.
The insured driver also denies the claimant’s allegation that he did not paid attention and failed to give the passengers enough time to put on the seat belts. He says he was travelling slowly because of other traffic. He says he was distracted because the other passenger had touched him as he was approaching the struck car.
After he exchanged particulars with the other driver, he continued the journey with the claimant and other passenger to Bondi. He also says they did not complain about any injuries during the ride.
The claimant had already been referred to orthopaedic surgeon Dr John Rooney who examined him shortly before the accident on 1 March 2023, who reported on the claimant’s left hip, knee and foot. He commented on a left hip and left knee MRI scans dated

13 January 2023. The scans were unremarkable with no inflammation or tears.
Neurosurgeon Mr Yanni Sergides saw the claimant about pain in the lumbar spine. His report dated 18 October 2023 and amended 1 November 2023 refers to symptoms related to the trauma sustained during this accident.
Sports and exercise specialist Dr Sharon Flahive reported on 21 November 2023 that she examined the claimant’s hips and found them normal. The claimant displayed restriction in his lumbar spine.
Sport and exercise medicine registrar Dr Thomas Cooney produced a report dated

15 March 2024. This report recorded that the insured driver was driving erratically at 50km/h before the accident. Relevantly to this Panel the claimant complained of left hip pain and left hip MRI scans showed evidence of a labral tear, gluteus medius tendinopathy trochanteric bursitis. He recommended the PRP injections.
The insurer filed a report dated 17 December 2024 from specialist radiologist Dr Tej Dugal commenting on whether the accident on 8 July 2023 could be a direct cause of the claimant’s alleged left hip, right shoulder and left shoulder conditions. It was lodged as an additional document in the portal. The claimant objected to the documents being considered.
However, the Panel considered it was relevant and would assist to resolve the dispute.
There had been earlier left hip scans and Dr Dugal’s analysis is as follows:
“The x-ray of the left hip dated 10/12/2019 and ultrasound of the left hip dated 13/12/2019 demonstrates no fracture or dislocation and sonographically, no abnormality has been demonstrated. To the limits of ultrasound, no paralabral ganglion cyst was noted.
The CT scan of the left hip dated 18/06/2022 performed at I-MED Radiology also demonstrates no fracture or dislocation. There is a small osteophyte from the superior head-neck junction of the femur indicative of early osteoarthritic changes. No effusion or dystrophic calcification is noted, and the soft tissue constraints of the hip appear normal.
MR arthrogram of the left hip dated 21/11/2024 performed at Castlereagh Imaging has been reviewed and as reported, there is an undisplaced tear of the anterior superior labrum. The tear shows areas of intermediate signal and no pure T2 fluid signal intensity indicating there are some granulation tissues indicating the tear is non-acute, and the arthrographic sequencing does not show T1 shortening to indicate contrast propagating into the tear, also confirming the presence of granulation tissue, and hence, confirming that the tear is non-acute. Remainder of the hip is notable for hip abductor tendinopathy and signal hyperintensity in the trochanteric bursa, and no osseous abnormality.
I note the MRI of the left hip performed at I-MED Radiology dated 01/12/2023 describes trochanteric bursitis and hip abductor tendinopathy consistent with the MR arthrogram. There is a report of a normal labrum, though on review of the images, there is a labral tear seen anterosuperiorly, less conspicuous than on the arthrographic series, but present. Similar to the latter MR imaging, there is intermediate signal within the tear in keeping with granulation tissue indicating that the tear is non-acute. Remainder of the study is within normal limits.
I also note that the image resolution on the I-MED examination is less than the Castlereagh Imaging, also accounting for the increased conspicuity on the latter arthrographic series.
Conclusion:
In my opinion, the hip abductor tendinopathy and trochanteric bursitis are common findings and the absence of tear of these structures and overlying soft tissue signal changes indicate haematoma and bruising, these findings are unrelated to trauma and, in my opinion, unrelated to the motor vehicle incident dated 08/07/2023. The tear of the anterior labrum is present on both MR studies and is non-acute given its granulation tissue as demonstrated by its intermediate signal changes and the absence of intra-articular gadolinium propagating into the tear. This confirms that the labral tear would predate the date of injury dated 08/07/2023, and hence, is unrelated to the motor vehicle trauma.”

Claimant’s submissions

The claimant provided his detailed submissions dated 5 December 2024 alleging the insurer had displayed a consistent pattern of disregarding established evidence, guidelines, and legal obligations, as highlighted by their actions in this case. He referred also to privacy breaches and successful complaints to the Australian Financial Complaints Authority.
He characterised the insurer as being bound by its earlier decisions to fund the treatment as contradicting the earlier prior acceptance of liability. Further, he refers to his treating doctors criticising the insurer for delaying his treatment for his accident related conditions.
The insurer funded the ﬁrst left hip MRI and Dr Chinappa’s consultation that identified the need for further testing with an MRI Arthrogram to investigate a potential labral tear.
The same specialist who assessed the left hip requested the left thigh MRI and left thigh nerve conduction study (NCS) after complications following the insurer funded left hip CT-guided cortisone injection, which the Allergy Clinic at North Shore Hospital and Specialists Report recorded. This left hip testing was to evaluate the extent of injury and adverse effects.
The insurer initially approved three PRP injections as part of the accident treatment plan. The insurer declined payment after the second treatment and the claimant was out of pocket for the final treatment.
Initially the insurer approved the consultation with Dr David Stewart (Hand and Wrist Surgeon) after the claimant’s treating orthopaedic surgeon Dr Sushil Pant requested it.
Dr Stewart’s referral was to identify appropriate treatment. Dr Sushil Pant’s clinical records confirm the need for additional assessment was reasonable and necessary.
The insurer’s reliance on a biomechanical report to dispute injury causation raised concerns about the insurer’s fairness and transparency. The claimant referred to criticism of this approach in “case law, regulatory findings, and industry standards that supports the validity of my claim and further underscore the insurer’s failure to act in good faith.”
He submitted the insurer’s biomechanical report was speculative as Australian courts have consistently prioritised medical evidence over biomechanical opinions, as seen in Marhaba v Chen [2024] ACTSC 241, which was relevant.
Medical Assessor Home relied on scans, treatment reports, clinical assessment and testing which demonstrated injuries including labral tears, gluteal tendinopathy, bursitis and nerve dysfunctions were consistent with the accident. These were more reliable than a biomechanical engineer. “Biomechanical reports can provide hypothetical context but cannot supersede clinical diagnoses or findings.”
The claimant contends that Medical Assessor Home considered the biomechanical report.
The insurer allegation about inconsistencies in symptom reporting and delays in reporting specific injuries is unfounded and unsupported by the evidence. The claimant characterises the allegations as deceptive and bullying. The claimant refers to the SIRA Whiplash Guidelines (3rd Edition, 2014) emphasising that “delayed symptom onset did not invalidate causation, the severity of symptoms is not correlated with vehicle damage, soft tissue and nerve injuries may not be visible on imaging but are clinically signiﬁcant, psychological factors like PTSD can impact recovery, and comprehensive management should address all related injuries…”
Sports physician Dr Cooney’s report commented on earlier injections and links the hip labral tears, gluteal tendinopathy, and greater trochanteric bursitis, to the ‘accident and recommended further management.
Hand and wrist surgeon Dr Stewart’s confirms bilateral cubital tunnel syndrome and right radial tunnel syndrome were linked to the accident. He recommended right cubital and radial tunnel surgical decompression and further treatment of the left upper extremity.
He argues that the insurer breached the Guidelines in respect to fairness, timeliness, “attempts to undermine the independence of the tribunal process, and consistent disregard for established medical evidence - represents a failure to act in good faith”.
The claimant’s supplementary submissions dated 4 February 2025 from Frisina Lawyers. That firm were instructed to act in relation to the Review on 24 January 2025. This firm subsequently withdrew.
The claimant’s statement dated 3 July 2024, at paragraph three records:
“The impact of the collision was severe due to my incorrect position. I was seated incorrectly by leaning toward my partner to help her secure her seatbelt for her safety because the driver refused to help as he drove off in a hectic way causing me to be thrown forward and then backward within the vehicle during the collision, keeping us in a state of shock.”
The claimant’s right shoulder, right elbow and right wrist, neck, left shoulder, left elbow and left wrist, low back, left hip and thigh injuries were reported contemporaneously or soon after the accident.

Approximately five years before this accident the claimant sought treatment for low back pain but there was no other complaint. Dr Sergides confirmed this in his report of 18 October 2023 and as amended on 1 November 2023.
Dr Rooney treated an earlier left knee condition that was in his GP’s clinical notes. He also underwent an MRI with respect to the left hip in January 2023.
Medical Assessor Home states at under the heading of “Additional/Late documents” in his reasons that he states, “Any additional/late documents have been considered.” The claimant submits that he was not obliged to specifically refer to Michael Griffiths’ biomechanical report.
The claimant provided a summary of all diagnostic imaging undertaken since the accident is in Annexure – Radiological and Treatment Evidence and Scan Index.
These were insurer funded investigations, performed under specialist referral, addressing the referred injuries. The claimant submitted these were clinically interpreted by treating specialists, radiologists, and the Commission’s medical assessors.
The claimant submitted “In the absence of new, material evidence, no lawful or clinical justification remains for further re-examination.”
The claimant also referred a separate dispute and the examination at the Commission’s rooms, where he felt intimidated during the examination. This enforced his view that he would not attend examinations he considered “medically unnecessary, legally unwarranted, and procedurally unsupported.”

Insurer’s submissions

The insurer submissions on the medicine are summarised under Medical Assessor Home’s findings above. The following summary, relevant to this Panel’s considerations addresses Medical Assessor Home not referring directly to Michael Griffiths biomechanical engineering report, which was submitted as a late document, the lack of reasoning and not testing the claimant’s consistency. The insurer submits it is essential to determine whether the accident was capable of causing the claimant’s alleged injuries.
The Medical Assessor did not provide sufficient reasons for determining the treatment was reasonable and necessary to treat accident related injuries. The insurer referred to relevant authorities on this point.[3]
[3] Ali v AAI Limited [2016] NSWCA 110; Insurance Australia v Milton [2016] NSWCA 156; Wingfoot v Kocak [2013] HCA 43 [4])
The insurer lodged additional documents Medical Assessor Home’s examination including the report of biomechanical engineer, Michael Griffiths. This was consented to by the claimant and admitted into evidence by Melinda Drew, the President’s Delegate, on 15 October 2024.
Before the report was provided Medical Assessor Home was on notice that the claimant had refused to attend the insurer’s medicolegal examinations and that a biomechanical engineer’s report would be served and relied on. The Medical Assessor’s reasons read as if he did not consider that report.
The insurer disputes that the accident was capable of causing the significant and widespread injuries alleged by the claimant.
Although the insurer refers five times to how the accident mechanism could have caused the referred injuries he does not refer to the report’s analysis of that mechanism.
Griffiths’ report contains relevant information that should have been addressed to properly determine the dispute.
The insurer referred to Campbell City Council v Vegan (2006) NSWCA 284 and other cases, to support its submission that where more than one conclusion is open, a Medical Assessor must explain why he or she prefers one conclusion over another. That aspect is significant where the Medical Assessor finds differently to submitted medical practitioners or experts’ findings.
The insurer also submits that Medical Assessor Home did not test consistency as required in cl 6.41 of the Guidelines and refers to relevant authorities.[4]
[4] QBE v Shah [2021] NSWSC 288
The insurer submits that the claimant has provided inconsistent descriptions of accident to the claimant’s treatment providers with respect to the severity of the accident and the injuries sustained.
The accident as the claimant describes to his treatment providers and the severity of injuries alleged are not what could be expected to occur as result of the forces involved in the collision. This would have informed the treatment provided and recommended by those treatment providers.
The insurer contends claimant provides various inconsistent histories, and delays reporting various injuries, which ought to have been raised with the claimant, when the Medical Assessor found, ‘the widespread physical complaints are atypical given the mechanism of accident.
Inconsistency must be questioned because the Medical Assessor note that the claimant “reports he is adamant that he did not have left hip pain prior to the accident”, when clinical records and specialist reports confirm hip complaints just months prior to the accident.
In respect to whether any of the treatment was reasonable and necessary the insurer’s submissions relied on there being no causal nexus between the accident and the need for the proposed treatment. It did not address whether the treatment was appropriate and would alleviate the claimant’s condition.

Panel deliberations

The Panel met twice. The inability to examine and obtain the claimant’s history of the collision created difficulties in testing the nexus between the accident and the referred injuries and considering the treatment.
The Panel discussed the claimant and his partner's statements. These read as submissions about the law and how the claim has been conducted, including friction between the claimant, his partner (who also applied for treatment and weekly payments arising from this accident) and the insurer.
Relying on his clinical judgement and experience Senior Medical Assessor Ian Cameron contributed his opinion on the available evidence and conferred with the balance of the Panel, which acknowledged that Medical Assessor Home found that the treatments were causally related to the July accident and reasonable and necessary, with the exception of the surgery to the nerve [redacted]. Medical Assessor Home provided a detailed report that comprehensively examined the issues.
The insurer requested a review of Medical Assessor Home’s report and the reason was that the Medical Assessor did not address Griffiths’ finding that the accident was a low velocity impact that was unlikely to cause the injuries that [CAK] had claimed.
Medical Assessor Rosenthal’s certificate dated 18 February 2025, addressed the insurer’s submissions on the traffic engineer’s report, which also denied a causal nexus between the claimant’s right shoulder condition and the accident.
[CAK] has provided detailed written submissions. He has declined to attend re-examination by the Review Panel. Therefore, his current status is not known, and it is not possible to review the post-accident history with reference to development of symptoms.
The history and examination provided by Medical Assessor Home is therefore accepted. The Panel noted that he provided detailed and cogent reasons for his determinations.
There was a clear chronology of when the claimant initiated medical treatment, but it was unclear when symptoms began. It would have assisted the Panel if the claimant had retained his legal representative who could have drafted short witness statements addressing only the circumstances of the accident, confirming the injuries, and in the claimant’s, case briefly referring to when the claimant experienced symptoms he says arose from the accident.
The claimant and his partner agree on the speed and that the claimant was assisting his partner when the collision occurred. The Panel discussed whether their estimates of the speed could carry weight, because neither of them were in position to observe the speedometer or possessed any expertise in estimating speed. Recollections do differ, but so do the drivers’ recollections.
The insured driver confirms there was movement in the back because he feels what he thinks is the claimant's partner touching him.
The claimant assisting the partner was relevant because when the collision occurred, he was not sitting squarely in his seat and that could have led to a torsion.
The insurer’s engineer discounts that potential torsion as being inconsequential, but it could be relevant, because the claimant and his partner say that was a factor in him being injured.
The engineer could have assisted the Panel by addressing why the claimant's corroborated contorted position at the time of the accident is irrelevant. The engineer relies on the claimant being wrong about the speed and force of impact to discount the treating doctors’ opinions on causation.
There is inconsistency between the insured driver and the car he hits. The insured driver says he was moving at about 25km/h and the other driver says he and the insured driver had halted and then the accident occurred. The engineer assumes the driver in front of the insured driver is correct but does not provide sufficient reasons why he prefers that version. The expert like this Panel had no scope for questioning both drivers and the passengers.
The claimant may been inconsistent or mistaken in his description of the speed the accident occurred at, but his treating doctors accept a nexus with the accident, despite the comments that the presentation of the claimant’s injuries were atypical.
Mr Griffith’s report states that the forces generated by the crash were insufficient to cause significant injury. This is largely based on the deformation that he observed in the bumper of the vehicle. Mr Griffith comments on the available medical information.
While the forces involved in a motor accident provide important information about the potential for injury, the actual injuries sustained in motor vehicle crashes are dependent on a much wider range of factors including background factors (age and gender), the person’s orientation and activity at the time of the crash, and post-crash factors.
This Panel considered the expert’s report too and noted the visible damage to both vehicles. The claimant’s position in the car, which is not challenged meant he would have been jolted when the insured car hit the car in front. If [CAK] was jolted forward in the position that he described, this could have caused most of the referred injuries.
The Review Panel accepted that while a traffic engineer’s opinion has weight when attempting to predict the injuries that a person may sustain in a motor vehicle accident, that opinion must also be balanced against evidence supporting a nexus between the alleged injuries and the accident. In this case the Panel is satisfied that the accident probably caused the referred injuries.

Does the proposed treatment relate to the injury resulting from the motor accident?

The Panel must decide whether the specified treatment “relates to the injury caused by the motor accident.” The common law test of causation under the MAI Act was discussed by the Supreme Court in Briggs No. 2.[5] These principles are well settled.
[5] Wright J in Briggs No. 2 [2022] NSWSC 372.
The motor accident need only be a material contribution to the need for treatment: AAI Limited v Phillips.[6] That case considered the words “whether any such treatment relates to the injury caused by the motor accident” where they appear in s 58(1) of the MAC Act. Those words are almost identical to the wording in Schedule 2 of the MAI Act.
[6] [2018] NSWSC 1710 at [29] (Phillips).
The Panel considered Dr Dugal’s opinion that the left hip changes were not related to the accident and his reasons. However, the preponderance of medical evidence regarding causation also supports a nexus with the accident, because complaints were made contemporaneously or soon after the accident and there were no intervening causes. Trauma related to the accident was a plausible explanation for the claimant’s complaints.
The Panel found the accident described materially contributed to the referred left hip injuries, because although the claimant had complained about his left lower limbs and had scans taken before the accident the complaints were mild, and scans showed no meaningful change. However, scans after the accident showed changes and the claimant’s complaints had intensified.
The Panel does not find that excising the [redacted] is the result of the accident. The mechanism of the accident described by any of the witnesses could not explain its presence or how an existing [redacted] could be aggravated.

Reasonable and necessary in the circumstances

[CAK] must establish that the treatment is both “reasonable and necessary.” This is a more onerous test than the NSW workers compensation legislation which requires a worker to establish that the treatment is “reasonably necessary.”
Workers compensation jurisdiction decisions provide some guidance though as when Grove J stated in Clampett v WorkCover Authority of NSW:
“22 I return to the expression ‘reasonably necessary’ in s60. Dictionaries stipulate that ‘necessary’ has relevant definition as ‘indispensable, requisite, needful, that cannot be done without’ - (Shorter) Oxford English Dictionary, 3rd Ed and ‘that cannot be dispensed with’ - Macquarie.
23 The essential issue is what effect flows from conditioning such qualities as ‘reasonably’. The consequence is to moderate any sense of the absolute which might otherwise be conveyed by the word ‘necessary’ if it stood alone. In order to contemplate such moderation, it is apt to consider surrounding circumstances, but the question to be addressed is whether modification of a worker's home, having regard to the nature of the worker's incapacity, is reasonably necessary. In contemplation of what might be "reasonably necessary" there is this statutory obligation specifically to have regard to the nature of the worker's incapacity. It provides emphasis towards moderating the meaning of ‘necessary’ in this context.”[7]
[7] [2003] NSWCA 52 (Clampett) at [22]-[23], Meagher & Santow JJA agreeing.
This draws the distinction with motor accidents legislation which requires two steps of considering whether there is a rationale for the treatment related to injury suffered in the subject accident; then addressing whether it is necessary.
However, key workers compensation decisions address the criteria of reasonableness. The late learned Deputy President Bill Roche listed these relevant considerations in Diab:[8]
“the appropriateness of the particular treatment;
the availability of alternative treatment;
the cost of the treatment;
the actual or potential effectiveness of the treatment, and
the acceptance by medical experts of the treatment as being appropriate or likely to be effective.”
[8] Diab v NRMA Ltd [2014] NSWWCCPD 2 (Diab) at [88].

Decision makers in the Commission’s Motor Accident Division have referred to those paragraphs of Diab as relevant considerations, which assist to establish whether proposed treatment is reasonable and necessary.[9]
[9] See Sarwary v Allianz Australia Insurance Limited [2023] NSWPICMP 125.
The words “in the circumstances” in the context of whether the treatment is “reasonable and necessary” must refer to the claimant’s particular circumstances. This follows Schedule 2 of the MAI Act which refers to treatment “provided or to be provided to the claimant”.
The insurer does not provide submissions on the merits of the proposed treatment but refers to Medical Assessor Home’s reasons failing to address that adequately.
The cost of the treatment is not discussed, and it would not be insubstantial although it does not require hospitalisation or surgery.
The supporting material does not question whether the proposed treatment is appropriate or whether the claimant should try alternative treatment. Medical Assessor Home’s reasons explain that referral to Dr Stewart, further MRI scans and nerve conduction studies are appropriate because the claimant is unable to have further diagnostic injections. That is a reasonable conclusion this Panel agrees with.
There are no comments on the effectiveness of the proposed treatments, but they are orthodox proposals, not at the forefront of medical care. Although PRP injections are relatively recent in terms of acceptance as to therapeutic value there are no objections to that proposed treatment other than lacking a causal link.
Applying the Panel’s Medical Assessors’ clinical knowledge and experience the proposed treatment and referring to the treating practitioners’ opinions the proposed treatment with a nexus to the accident is reasonable and necessary in the circumstances.

CONCLUSION

The Panel determines the following:
Surgery
·the physical injuries giving rise to the need to excise the right tibial nerve presumed nerve [redacted] were not related to an injury caused by the accident, and
·the physical injuries giving rise to a need for excision of the right tibial nerve presumed nerve [redacted] is not reasonable and necessary in the circumstances.
Radiological investigations
·the physical injuries giving rise to a need for the left hip MRI relates to the injury caused by the motor accident;
·the physical injuries giving rise to a need for MRI of the left hip is reasonable and necessary in the circumstances;
·the physical injuries giving rise to a need for the left thigh MRI relates to the injury caused by the motor accident, and
·the physical injuries giving rise to a need for the left thigh is reasonable and necessary in the circumstances.
Nerve Conduction Study
·the physical injuries giving rise to a need for a nerve conduction study of the left thigh relates to the injury caused by the motor accident, and
·the physical injuries giving rise to a need for nerve conduction study of the left thigh is reasonable and necessary in the circumstances.
PRP Injections
·the physical injuries giving rise to a need for PRP injections relates to the injury caused by the motor accident, and
·the physical injuries giving rise to a need for PRP injections is reasonable and necessary in the circumstances.
Medical Specialist Consultation
·the physical injuries giving rise to a need for referral to hand and wrist surgeon Dr David Stewart, relates to the injury caused by the motor accident, and
·the physical injuries giving rise to a need for referral to hand and wrist surgeon Dr David Stewart, is reasonable and necessary in the circumstances.
The Panel has made the same decision as Medical Assessor Home.
Medical Assessor Home’s certificate dated 3 October 2024 regarding whether the proposed medical treatment was reasonable and necessary is affirmed.

[2025] NSWPICMP 698

11 September 2025