Lewis v AAI Limited T/As AAMI (Motor Accident Injuries)

The applicant, Lewis, appealed against the respondent AAI Limited T/As AAMI's decision to approve only four hours per week of attendant care services as part of her recovery plan, following a motor vehicle accident. The dispute centred on whether the insurer could consider the applicant's funding under the National Disability Insurance Scheme (NDIS) when determining the reasonableness and necessity of the proposed treatment and care under section 126(2) of the Motor Accident Injuries Act. The applicant argued that her NDIS entitlements should not be a factor in the insurer's decision, while the insurer maintained that the internal reviewer had not erred in considering the NDIS funding.

The key legal issues the tribunal had to decide included whether the internal reviewer erred in taking into account the applicant's NDIS funding when determining the reasonableness and necessity of the treatment and care, and whether the insurer erred in relying on an occupational therapist's opinion regarding the treatment and care, given that it pertained to a psychiatric injury. The tribunal examined whether the internal reviewer's consideration of the NDIS funding constituted an error of fact or law, and whether the occupational therapist's opinion was relevant and qualified.

The tribunal found that the internal reviewer erred in considering the applicant's NDIS funding when determining what treatment and care was reasonable and necessary. The tribunal held that the NDIS funding should not have influenced the decision on the reasonableness and necessity of the treatment and care. Additionally, the tribunal found that the insurer erred in relying on the occupational therapist's opinion, as the therapist was not qualified to provide an opinion on psychiatric injuries. Based on the available medical evidence, the tribunal concluded that twenty-three and a half hours per week of attendant care services were reasonable and necessary. The tribunal set aside the internal review decision and substituted it with a decision approving twenty-three and a half hours per week of attendant care services.

The tribunal ordered that the respondent's decision approving four hours per week of support worker assistance was set aside, and in substitution, approved attendant care services for twenty-three and a half hours per week. This decision affirmed the necessity of considering the applicant's medical needs independent of her NDIS funding and ensured that qualified professionals provided opinions on psychiatric injuries.