AAI Limited t/as AAMI v Shoyeb - [2025] NSWPICMP 122

DETERMINATION OF REVIEW PANEL
CITATION:	AAI Limited t/as AAMI v Shoyeb [2025] NSWPICMP 122
CLAIMANT:	G M Shoyeb
INSURER:	AAI Limited t/as AAMI
REVIEW PANEL
MEMBER:	Belinda Cassidy
MEDICAL ASSESSOR:	Les Barnsley
MEDICAL ASSESSOR:	Ian Cameron
DATE OF DECISION:	26 February 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; claim for three updated or repeat MRIs; Medical Assessor (MA) determined the treatment was related to the injuries sustained in the accident and was reasonable and necessary in the circumstances; claimant injured in motor accident on 26 November 2021; sustained fractured left wrist; Review Panel satisfied soft tissue injuries to neck, lower back, and right knee; claimant had three MRIs in January (cervical and lumbar spine) and March 2022 (right knee); orthopaedic surgeon advised conservate treatment of neck and back and MRI of right knee was completely normal; claimant complained of worsening pain in October/November 2023 but no new symptoms; insurer’s medico legal had history of resolving lower back and knee pain and claimant’s medico legal had no report of knee pain and intermittent back pain; Held – Review Panel determined not to re-examine claimant and determined the dispute on the papers; section 42 of the Personal Injury Commission Act 2020 referred to and Sydney Trains v Batshon distinguished; Review Panel satisfied treatment in dispute related to injuries resulting from the accident but not satisfied treatment was reasonable and necessary in the circumstances; Rose v Health Commission NSW, Clampett v Workcover Authority (NSW), Moorebank Recyclers Pty Limited v Tanlane Pty Limited, and Diab v NRMA referred to; Medical Assessment Certificate 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 of Medical Assessor Shahzad dated 11 September 2024. 2. Certifies that the MRI scans requested of the claimant’s cervical spine, lumbar spine and right knee are related to the injuries resulting from the motor accident on 26 November 2021 but are not reasonable and necessary in the circumstances. A statement setting out the Review Panel’s reasons for the assessment is included with this certificate.

STATEMENT OF REASONS

INTRODUCTION

Mr Shoyeb was involved in a motor accident on 26 November 2021.
Mr Shoyeb says he injured his neck, back and right knee in the accident and made a claim for statutory benefits with AAMI, the third-party insurer of the vehicle that he says caused his accident.
A medical dispute about treatment (MRI scans for the neck, back and right knee) has arisen in connection with that claim and Mr Shoyeb referred that dispute to the Personal Injury Commission (the Commission) for assessment.
On 11 September 2024, Medical Assessor Shahzad determined that Mr Shoyeb’s requested treatment related to the injuries caused by the motor accident and was reasonable and necessary in the circumstances.
The insurer lodged an application with the Commission seeking a review of the Medical Assessor’s decision. The claimant did not lodge a reply to that application.
On 21 November 2024,…

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.

Keep reading for free

Create a free CaseChat account to read AAI Limited t/as AAMI v Shoyeb and more:

Read every judgment in full
Ask AI and get answers linked to paragraphs
See how each paragraph was cited in later cases
Download judgments as PDF or Word

Continue with Google

One click creates your free account or signs you in.

By continuing you agree to the Terms and Privacy Policy.

Details

Case: [2025] NSWPICMP 122
Decision Date: 26 February 2025

CaseChat Overview and Summary

In the matter of AAI Limited trading as AAMI against Shoyeb, the Federal Circuit and Family Court of Australia was tasked with resolving a dispute concerning the claimant's entitlement to three updated or repeat Magnetic Resonance Imaging (MRI) scans. The claimant, Shoyeb, sustained injuries in a motor accident on 26 November 2021, which included a fractured left wrist and soft tissue injuries to his neck, lower back, and right knee. The insurer, AAI Limited trading as AAMI, initially approved three MRIs, but later questioned the necessity of these scans as the claimant's condition evolved.

The court had to determine whether the treatment in dispute was related to the injuries sustained in the accident and whether it was reasonable and necessary under the circumstances. The Review Panel was satisfied that the treatment related to the injuries resulting from the accident. However, they were not convinced that the treatment was reasonable and necessary. The Panel cited several cases, including Rose v Health Commission NSW, Clampett v Workcover Authority (NSW), Moorebank Recyclers Pty Limited v Tanlane Pty Limited, and Diab v NRMA, to support their decision. The Panel also considered the statutory provisions under section 42 of the Personal Injury Commission Act 2020 and distinguished Sydney Trains v Batshon in their analysis.

The Review Panel determined not to re-examine the claimant and instead resolved the dispute based on the documentation submitted. They concluded that while the treatment was related to the injuries from the accident, it was not reasonable and necessary in the circumstances. Consequently, the Panel revoked the Medical Assessment Certificate. This decision underscores the importance of the nexus between the treatment and the injuries sustained, as well as the necessity of the treatment under the prevailing conditions.

Orders