Johnston v QBE Insurance (Australia) Limited

In the case of Johnston v QBE Insurance (Australia) Limited, the dispute centered around the claimant's shoulder surgery following a motor accident, and whether the insurer was obligated to cover the costs under the Motor Accidents Compensation Act 1999. The Medical Assessor had previously ruled that the surgery was neither related to the accident injuries nor reasonable and necessary, as it had already been performed at the time of the initial assessment. Johnston challenged this decision, asserting that the injury from the accident necessitated the surgery.

The court had to determine whether the injury suffered in the accident was a material cause of the claimant's need for shoulder surgery and if the surgery was reasonable and necessary under the circumstances. The Panel examined the evidence and the Medical Assessor's determination, ultimately finding that the claimant had indeed injured his left shoulder in the accident, with a diagnosis of bursitis, impingement, and a likely capsular strain. Given that this injury was a significant contributing factor to the surgery, the Panel concluded that the surgery was related to the accident and, thus, reasonable and necessary.

The court referred to several cases in its reasoning, including AAI Limited t/as AAMI v Phillips to establish causation, Diab v NRMA Limited to assess reasonableness, and Clampett v Workcover Authority of NSW to determine necessity. The Panel's decision overturned the Medical Assessor's finding, holding that the insurer must cover the costs of the surgery. The final orders were that QBE Insurance (Australia) Limited was to pay for the surgery and any associated costs, as the injury from the accident was a material cause of the need for surgery.