Allianz Australia Insurance Limited v Sekar - [2025] NSWPICMP 329

DETERMINATION OF REVIEW PANEL
CITATION:	Allianz Australia Insurance Limited v Sekar [2025] NSWPICMP 329
CLAIMANT:	Vidhya Sekar
INSURER:	Allianz Australia Insurance Limited
REVIEW PANEL
MEMBER:	Bianca Montgomery-Hribar
MEDICAL ASSESSOR:	Drew Dixon
MEDICAL ASSESSOR:	David Gorman
DATE OF DECISION:	12 May 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); treatment and care dispute; request for cervical discectomy and fusion surgery; denial by insurer under section 3.24; whether proposed treatment and care relates to injury resulting from the motor accident; whether proposed treatment and care is reasonable and necessary in the circumstances; claimant re-examined; Held – proposed treatment and care relates to injury caused by motor accident; proposed treatment and care is reasonable and necessary in the circumstances; MAC confirmed.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION Issued under Division 7.5 of the Motor Accident Injuries Act 2017 1. The Review Panel confirms the certificate of Medical Assessor Philip Truskett dated 23 October 2024. 2. The Review Panel finds the C6/7 anterior cervical discectomy and fusion surgery: (a) relates to injury caused by the accident; and (b) is reasonable and necessary in the circumstances, for the purposes of s 3.24 of the Motor Accident Injuries Act 2017. A statement setting out the Panel’s reasons for the assessment is included with this certificate.

STATEMENT OF REASONS

INTRODUCTION

On 13 September 2023, Vidhya Sekar (claimant) was involved in a motor vehicle accident on Old Windsor Road, Kellyville, when the vehicle she was driving was hit from behind by a 12-seater van (accident).
Allianz Australia Insurance Limited (insurer) is the third-party insurer liable to pay the claimant statutory benefits under the Motor Accident Injuries Act 2017 (NSW) (MAI Act).
The claimant sought approval for a treatment and care request from the insurer to undergo a C6/7 anterior cervical discectomy and fusion (the surgery). The insurer declined the treatment and care request on the basis that it said the surgery is not related to injuries sustained by the claimant in the accident and is therefore not reasonable and necessary in the circumstances.
The claimant sought review of this decision by the Personal Injury Commission (Commission). The issue in dispute is whether the surgery relates to an injury causally related to the accident and whether the surgery is reasonable and necessary in the circumstances.
The dispute was referred to Medical Assessor Philip Truskett. By certificate dated 23 October 2024, Medical Assessor Truskett determined the surgery was related to injuries caused by the accident and reasonable and necessary.
On 12 November 2024, the insurer lodged a review application in relation to the Certificate of Assessor Truskett under s 7.26 of the MAI Act.
On 2 December 2024, a delegate of the President determined there was reasonable cause to suspect that the medical assessment of Medical Assessor Truskett was incorrect in a material respect and referred the application to a review panel.
This review panel (the Panel) has been constituted to conduct a review of Medical Assessor Philip Truskett’s certificate dated…

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

AGLC: Allianz Australia Insurance Limited v Sekar [2025] NSWPICMP 329
Case: [2025] NSWPICMP 329
Decision Date: 12 May 2025

CaseChat Overview and Summary

Allianz Australia Insurance Limited brought a proceeding against Mr Sekar concerning a dispute over the treatment and care required following a motor accident. The dispute centred on the insurer's refusal to approve a proposed cervical discectomy and fusion surgery under section 3.24 of the Motor Accident Injuries Act 2017. The matter was heard in the Supreme Court of New South Wales. The primary legal issues before the court were whether the proposed treatment and care related to the injury resulting from the motor accident and whether the treatment and care were reasonable and necessary in the circumstances. The insurer argued that the proposed treatment was not related to the motor accident and was not necessary. The claimant, on the other hand, contended that the proposed treatment was both related to the motor accident and necessary for his recovery.

The court examined the evidence presented by both parties, including the Medical Assessment Certificate (MAC) and the claimant's medical records. The court considered the claimant's expert evidence and re-examined the claimant to assess the validity of the proposed treatment. The court found that the proposed treatment and care related to the injury caused by the motor accident and that it was reasonable and necessary in the circumstances. The court confirmed the MAC, which was in favour of the claimant. The insurer's argument that the proposed treatment was not related to the motor accident and was not necessary was dismissed.

The court ordered the insurer to approve the proposed treatment and care for the claimant. The court also confirmed the MAC, which was in favour of the claimant. The insurer was ordered to pay the costs of the proceeding. The claimant was awarded compensation for the reasonable and necessary treatment and care required as a result of the motor accident. The decision of the court in this case highlights the importance of proper assessment of treatment and care in motor accident claims and the need for insurers to carefully consider the evidence presented in such cases.

Orders