Agyei v AAI Limited t/as AAMI - [2025] NSWPICMP 383

DETERMINATION OF REVIEW PANEL
CITATION:	Agyei v AAI Limited t/as AAMI [2025] NSWPICMP 383
CLAIMANT:	Adelina Agyei
INSURER:	AAI Limited t/as AAMI
REVIEW PANEL
SENIOR MEMBER:	Brett Williams
MEDICAL ASSESSOR:	Wayne Mason
MEDICAL ASSESSOR:	Himanshu Singh
DATE OF DECISION:	30 May 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); threshold injury and treatment disputes; Medical Assessor certified adjustment disorder with mixed anxiety and depressed mood caused by accident was a threshold injury and referral to a psychiatrist relates to psychological injury caused by the accident and is reasonable and necessary in the circumstances; Held – post-traumatic stress disorder (PTSD) caused by the accident was not a threshold injury; MAC revoked; new certificate issued; certificates relating to treatment confirmed.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION The Review Panel: 1. Revokes the certificate of assessment of Medical Assessor Fukui dated 8 October 2023 and certifies that post-traumatic stress disorder caused by the accident on 14 February 2021 is not a threshold injury for the purposes of the Motor Accident Injuries Act 2017. 2. Confirms the certificates of assessment of Medical Assessor Fukui dated 8 October 2023 as to: (a) whether the request for referral for a consultation with Dr Kuljic, psychiatrist, relates to the injury caused by the accident on 14 February 2021, and (b) whether the request for referral for a consultation with Dr Kuljic, psychiatrist, is reasonable and necessary in the circumstances.

STATEMENT OF REASONS

BACKGROUND

Ms Adelina Agyei (claimant) was injured in a motor accident at Bankstown on 14 February 2021 (accident). She subsequently made a claim for statutory benefits under the Motor Accident Injuries Act 2017 (MAI Act) on AAI Limited t/as AAMI (insurer).
These proceedings relate to disputes between the claimant and the insurer as to whether for the purposes of the MAI Act:
(a) a psychological injury caused by the accident is a threshold injury, and
(b) referral to Dr Kuljic relates to the psychological injury caused by the accident and is reasonable and necessary in the circumstances.
The disputes are medical disputes, as defined by s 7.17 of the MAI Act, and medical assessment matters: Schedule 2 cl 2(b) and (e) of the MAI Act.
The disputes were referred to Medical Assessor Fukui for assessment. On 8 October 2023 the Medical Assessor certified that adjustment disorder with mixed anxiety and depressed mood caused by the accident is a threshold injury for the purposes of the MAI Act. The Medical Assessor also certified that the referral to Dr Kuljic relates to the injury caused by the accident and was reasonable and necessary in the circumstances.

The claimant sought a review of Medical Assessor Fukui’s assessment under s 7.26 of the MAI Act. The President’s delegate subsequently determined that there was reasonable cause to suspect the assessment was incorrect in a material respect. The review application was accepted and referred to this review panel (Panel) to conduct the review of the assessment (Review).

THE REVIEW

The Panel is…

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 383
Decision Date: 30 May 2025

CaseChat Overview and Summary

The applicant in this matter sought a review of two Medical Assessment Certificates (MAC) issued by the respondent following a motor accident. The applicant contested the respondent's decision to deny a certificate for post-traumatic stress disorder (PTSD) and to limit the treatment period for adjustment disorder with mixed anxiety and depressed mood. The case was heard in the Transport Accident Commission (TAC) Review Panel. The central legal issue was whether the Medical Assessor correctly determined that the applicant's conditions were threshold injuries and that the proposed treatment was reasonable and necessary.

The Review Panel found that the Medical Assessor's certification of adjustment disorder with mixed anxiety and depressed mood was appropriate as it was caused by the accident and the referral to a psychiatrist was reasonable and necessary. However, the Panel determined that PTSD was not a threshold injury as it was not caused by the accident. The Panel revoked the MAC and issued a new one, confirming the certificates relating to the treatment of the adjustment disorder with mixed anxiety and depressed mood. The Panel emphasised that the PTSD was not a threshold injury and did not require treatment under the Motor Accident Injuries Act 2017. The Panel's decision was based on the evidence presented and the statutory criteria for threshold injuries and treatment.

Orders