Begonja v Insurance Australia Group Ltd Trading as NRMA Insurance (Motor Accident Injuries)

The case of Begonja v Insurance Australia Group Ltd Trading as NRMA Insurance involved a dispute concerning the denial of coverage for ketamine treatment for motor accident injuries. The applicant, Ms Begonja, sought a review of the insurer’s decision under section 193 of the Motor Accident Injuries Act 2019. The primary issue before the court was whether the insurer’s decision to deny coverage for the ketamine treatment was lawful and based on the correct interpretation of the applicable provisions of the Act.

The court examined the legal framework governing the review process, particularly the role of the tribunal in conducting a review of the insurer’s decision. The tribunal's role was limited to reviewing the legality of the decision rather than conducting a merits review. The court noted that the tribunal could only consider information that was available to the insurer at the time of making the decision, unless permission was granted for additional information to be presented. In this case, the insurer provided a comprehensive set of documents, and additional documents were allowed to be presented following applications by both parties.

The court concluded that the insurer's decision to deny coverage for the ketamine treatment was lawful. The insurer had relied on research papers and best practice guidelines that did not support the use of ketamine infusions for managing persistent pain. The court found that the insurer had not made an error of law or fact in denying the treatment, and accordingly, affirmed the insurer’s decision.

The tribunal orders affirmed the insurer’s decision of 27 April 2021, denying liability for the cost of ketamine treatment.