Harris v AAI Limited t/as AAMI - [2024] NSWPICMP 125

DETERMINATION OF REVIEW PANEL
CITATION:	Harris v AAI Limited t/as AAMI [2024] NSWPICMP 125
CLAIMANT:	Craig Harris
INSURER:	AAI Limited t/as AAMI
REVIEW PANEL
MEMBER:	Belinda Cassidy
MEDICAL ASSESSOR:	Drew Dixon
MEDICAL ASSESSOR:	Sophia Lahz
DATE OF DECISION:	5 March 2024
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; claimant’s application for review of Medical Assessor (MA) Herald’s decision that treatment (including knee replacement surgery) was not reasonable and necessary and not related to the injuries caused by the accident; claimant hit from the left and fell off his motor bike onto his right side on 16 May 2020; hospital notes and GP records did not record any specific right knee symptoms for 13 months after the accident; claimant had previous right knee injury and some symptoms a few years before the accident; claimant had advanced osteo-arthritis in the right knee and needed the surgery and related treatment which the Panel found reasonable and necessary in the circumstances however the Panel determined that the surgery (and related treatment) was not caused by the accident due to the claimant’s pre-accident history, the absence of specific knee complaints for six months after the accident and no record of knee complaints until 13 months after the accident; Held – Medical Assessor’s certificate confirmed.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION Issued under Division 7.5 of the Motor Accident Injuries Act 2017 The Review Panel: 1. Affirms the certificate issued by Medical Assessor Herald dated 20 June 2023, and 2. Certifies that the treatment in dispute does not relate to the injury caused by the motor accident.

STATEMENT OF REASONS

INTRODUCTION

Craig Harris was involved in a motor accident on 16 May 2020. He was riding his motor bike when he was struck by another vehicle which was merging from the left into Mr Harris’ lane.
Mr Harris says he injured his right knee in the accident. He made a claim for statutory benefits against AAMI, the third-party insurer of the vehicle that Mr Harris says caused his accident. AAMI appears to accept it is the relevant insurer and has been paying Mr Harris his statutory benefits.
A medical dispute about certain treatment and care has arisen in connection with that claim and Mr Harris referred that dispute to the Personal Injury Commission (the Commission) for assessment.
On 20 June 2023, Medical Assessor Herald determined that none of the treatment in dispute was related to the accident.
The insurer then lodged an application with the Commission seeking a review of the Medical Assessor’s decision. On 26 October 2023, a delegate of the President determined there was reasonable cause to suspect a material error in the assessment and allowed the Review. On 31 October 2023 the President’s delegate convened this Panel to conduct the Review.

LEGISLATIVE FRAMEWORK

Jurisdiction

Mr Harris’ claim is governed by the provisions of the Motor Accident Injuries Act 2017 (the MAI Act). This legislation provides a scheme for the compulsory third-party insurance of all motor vehicles registered in New South Wales…

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: [2024] NSWPICMP 125
Decision Date: 5 March 2024

CaseChat Overview and Summary

In the matter of Harris v AAI Limited t/as AAMI, the claimant sought a review of a decision made by a Medical Assessor (MA) who determined that a treatment plan, including knee replacement surgery, was not reasonable and necessary for injuries sustained in a motor accident. The claimant had been involved in a motorcycle accident on 16 May 2020, where he was hit from the left and subsequently fell off his bike onto his right side. The claimant had a pre-existing condition of advanced osteoarthritis in his right knee, which had been symptomatic a few years before the accident. Following the accident, the claimant did not report any specific right knee symptoms for thirteen months, as evidenced by hospital notes and general practitioner records.

The legal issues before the court centred on whether the treatment, including the knee replacement surgery, was reasonably necessary and related to the injuries caused by the motor accident. The claimant argued that the surgery was necessary given the advanced osteoarthritis and the impact of the accident, while the MA found that the treatment was not caused by the accident due to the claimant's pre-accident history and the absence of specific knee complaints immediately following the accident. The court was tasked with determining whether the MA's decision was legally sound and supported by the evidence presented.

The court examined the evidence, including the claimant's medical history, the timeline of reported symptoms, and the MA's assessment. It was noted that the claimant had a documented history of right knee issues prior to the accident, and there were no immediate reports of knee pain or symptoms following the accident. The claimant did not report any specific right knee symptoms until thirteen months after the accident, which the court considered in assessing the causal link between the accident and the need for surgery. The court found that the MA's decision was reasonable and adequately supported by the evidence, confirming that the treatment, including the knee replacement surgery, was not reasonably necessary as a result of the motor accident. The court upheld the MA's certificate, finding it to be legally justified.

Orders