Suarez v AAI Limited ACN 005 297 807 Trading as AAMI (Motor Accident Injuries)

In this matter, the applicant, Suarez, sought review of a decision by AAI Limited, trading as AAMI, to deny payment for twenty-two group exercise sessions as part of her treatment and care expenses following a motor accident. The dispute arose from the internal review decision dated 16 February 2021, which affirmed the original decision of the AAMI Claims Team to refuse coverage for the requested sessions. Suarez argued that she continued to experience symptoms and required a more targeted recovery plan.

The key legal issues before the court were whether the requested treatment was reasonable and necessary, whether it provided benefit to Suarez, and whether it was cost-effective. The court needed to determine whether the insurer's decision to deny the group exercise sessions was in accordance with the Motor Accident Injuries Act 2019. The court also needed to consider the evidence provided by Dr Ostberg and Dr Wallace, including their diagnoses, recommendations, and observations about Suarez's condition and the effectiveness of the proposed treatment.

The court examined the internal review decision and the evidence presented by the parties. It found that the insurer had not adequately justified its decision to deny the group exercise sessions. The court noted that Suarez continued to experience symptoms and that a more targeted recovery plan, including the group exercise sessions, was warranted. The court held that the insurer's decision was not in accordance with the Motor Accident Injuries Act 2019 and set aside the internal review decision. The court ordered the insurer to pay for the twenty-two group exercise sessions as part of Suarez's treatment and care expenses.

The court's final order was that the respondent's internal review decision dated 16 February 2021 to refuse to pay for twenty-two group exercise sessions is set aside. The respondent is to pay the cost of a course of group exercise sessions recommended in Allied Health Recovery claim entitled Request No. 2 – Physiotherapy.