Neysie v AAI Limited t/as AAMI - [2024] NSWPICMP 423

DETERMINATION OF REVIEW PANEL
CITATION:	Neysie v AAI Limited t/as AAMI [2024] NSWPICMP 423
CLAIMANT:	Foad Neysie
INSURER:	AAI Limited ABN 48 005 297 807 t/a AAMI
REVIEW PANEL
MEMBER:	Terence Stern OAM
MEDICAL ASSESSOR:	Geoffrey Stubbs
MEDICAL ASSESSOR:	Sophia Lahz
DATE OF DECISION:	28 June 2024
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; claimant suffered injury in a motor vehicle accident; Medical Assessor determined that the proposed treatment disputes were not caused by the motor accident; issue of causation considered according to section 6.6 of the Motor Accident Guidelines; Held – proposed treatment for left knee arthroscopy was causally related to the accident and was reasonable and necessary in the circumstances; proposed treatment and care for left shoulder surgery did not relate to the injury caused by the motor accident; Medical Assessment Certificate revoked.
DETERMINATIONS MADE:	CERTIFICATE OF DETERMINATION 1. The Review Panel revokes the certificate of Medical Assessor Cameron dated 26 August 2023. 2. The Review Panel substitutes the following determination and issues a new certificate to certify that: · the proposed treatment and care for left knee arthroscopy surgery does relate to the injury caused by the motor accident and is reasonable and necessary in the circumstances, and · the proposed treatment and care for left shoulder surgery does not relate to the injury caused by the motor accident.

STATEMENT OF REASONS

INTRODUCTION

On 3 August 2019, Foad Neysie (the claimant), was driving a Toyota Hiace van when it was involved in a collision between the front left side of his vehicle, and the front right side of the other vehicle.
The police and ambulance attended, and Mr Neysie was taken to Ryde Hospital where he remained a short time.
AAMI is liable to pay Mr Neysie the cost of medical treatment, under the Motor Accidents Injuries Act 2017 (MAI Act).

The following treatment disputes were referred by the Personal Injury Commission (Commission) for assessment:
(a)    whether the request for a left knee arthroscopy is causally related to the injuries sustained in the motor vehicle accident (the accident);
(b)    whether the request for a left knee arthroscopy is reasonable and necessary in relation to the injuries sustained in the accident;
(c)    whether proposed left shoulder surgery is causally related to the injuries sustained in the accident, and
(d)    whether proposed left shoulder surgery is reasonable and necessary in relation to the injuries sustained in the vehicle accident.
Medical Assessor Cameron certified that the following treatment:

(a) proposed left knee arthroscopy, and
(b) the proposed left shoulder surgery,
did relate to the injuries caused by the motor accident.

Medical Assessor Cameron found that the following treatment and care:
(a) proposed left knee arthroscopy, and
(b) the proposed left shoulder surgery,
were not reasonable and necessary in the circumstances.

THE REVIEW

Mr Neysie requested referral to a Review Panel (the Panel) on the basis that there was reasonable cause to suspect that the Medical Assessor was incorrect in a material respect.
The review of the medical…

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 423
Decision Date: 28 June 2024

CaseChat Overview and Summary

The claimant in this case, Neysie, brought an action against AAI Limited t/as AAMI in the Civil and Administrative Tribunal of New South Wales. Neysie, the claimant, suffered injuries in a motor vehicle accident and sought compensation and medical treatment under the Motor Accident Injuries Act 2017. The dispute centred around the assessment of whether certain proposed medical treatments were causally related to the motor accident and whether they were reasonable and necessary.

The primary legal issue before the court was to determine if the proposed treatments for left knee arthroscopy and left shoulder surgery were causally connected to the motor accident. This determination was guided by section 6.6 of the Motor Accident Guidelines, which provides criteria for assessing causation in such matters. The court had to decide whether the treatments were necessary and reasonable in light of the injuries sustained in the accident.

The court found that the proposed treatment for left knee arthroscopy was causally related to the motor accident. The injury to the knee was a direct result of the accident, and the proposed treatment was deemed reasonable and necessary. Conversely, the court determined that the proposed treatment for left shoulder surgery did not relate to the injury caused by the motor accident. This conclusion was based on the evidence presented, which did not establish a causal link between the shoulder injury and the accident. As a result, the Medical Assessment Certificate issued by AAI Limited was revoked.

The final orders of the court mandated that AAI Limited was to cover the costs of the knee arthroscopy treatment, while the costs for the shoulder surgery treatment were to be borne by Neysie. This decision underscored the importance of establishing causation in determining the scope of compensation and treatment under the Motor Accident Injuries Act.

Orders