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

In the case of Lewis v AAI Limited T/As AAMI (Motor Accident Injuries), the applicant sought a review of a decision made by the insurer, which had been affirmed on internal review. The applicant argued that the insurer improperly considered her National Disability Insurance Scheme (NDIS) entitlements when determining the reasonableness and necessity of treatment and care for her post-traumatic stress disorder (PTSD) resulting from a motor vehicle accident. The applicant also contended that the insurer wrongly relied on an occupational therapist's opinion instead of a psychiatrist's opinion for her psychiatric injury. The central legal issue was whether the insurer was entitled to take into account the applicant’s NDIS entitlements and whether the occupational therapist’s opinion was appropriate in this context.

The Tribunal found that the internal reviewer made an error by considering the applicant’s NDIS funding, which was not a relevant factor in determining the reasonableness and necessity of the treatment and care. Furthermore, the Tribunal concluded that the insurer erred in relying on the occupational therapist's opinion instead of a psychiatrist's opinion for the applicant's psychiatric injury. Given the available medical evidence, the Tribunal determined that twenty-three and a half hours per week of attendant care services were reasonable and necessary in the circumstances. Therefore, the Tribunal set aside the internal review decision and approved attendant care services for twenty-three and a half hours per week.

The Tribunal's decision underscores the importance of considering the appropriate type of medical expertise when evaluating treatment and care for specific injuries. Additionally, it clarifies that NDIS entitlements should not influence the determination of reasonable and necessary treatment and care under the Motor Accident Injuries Act. The Tribunal's final orders included setting aside the insurer's decision approving four hours of support worker assistance per week and substituting it with approval for twenty-three and a half hours of attendant care services per week.