AAI Limited t/as AAMI v CAK - [2025] NSWPICMP 698

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…

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 698
Decision Date: 11 September 2025

CaseChat Overview and Summary

AAI Limited trading as AAMI (the insurer) sought a review of a decision by a Medical Assessor (MA) in relation to a claim for motor accident injuries sustained by CAK (the claimant). The dispute centred on whether the accident on 8 July 2023 caused the claimant's injuries and whether the treatment provided was reasonable and necessary. The case was heard in the Court of Appeal Tribunal (CAT).

The legal issues before the court were whether the MA correctly found a causal nexus between the accident and the treatment, and whether the claimant's injuries were reasonably and necessarily caused by the accident. The insurer contested the MA’s certificate, arguing that the forces involved in the accident were insufficient to cause the claimant's injuries and that the claimant had provided inconsistent accounts of the accident to various treatment providers. The insurer relied on an expert report from a biomechanical engineer to support their position. The claimant, however, refused to attend a re-examination requested by the insurer.

The Review Panel examined the opinions of the claimant's treating doctors and the MA regarding the nexus with the accident. The Panel concluded that the accident mechanism could reasonably cause the claimant's injuries, and the clinical judgment was that it was probable that the accident caused the referred injuries. The evidence supported this conclusion, and the treatment provided was deemed appropriate. The court found that section 3.24 of the Motor Accidents Injuries Act 2017 was correctly applied by the MA, and the original certificate was confirmed.

The final orders confirmed that the accident caused the claimant's injuries and that the treatment was reasonable and necessary. The Review Panel’s original certificate was upheld, and the insurer's review application was dismissed.

Orders