Claimants seeking statutory benefits for medical treatment following a motor vehicle accident must be mindful of several critical factors, as demonstrated in the decision El-Kazzi v Insurance Australia Limited t/as NRMA Insurance [2024] NSWPICMP 591 handed down by the Personal Injury Commission (PIC) on 6 September 2024.
Background
The claimant sought approval for perineural blocks and a cervical discectomy and fusion surgery, claiming injuries to his cervical spine and both shoulders following a motor vehicle accident on 9 November 2019. The insurer challenged whether these specific medical treatments were truly reasonable and necessary, which raise important considerations for claimants navigating these claims.
Relevant provisions
Under section 3.24 of the Motor Accident Injuries Act 2017 (MAIA), claimants are entitled to statutory benefits for medical treatment and care if it is deemed reasonable, necessary, and related to injuries caused by the motor vehicle accident. This provision requires claimants to provide solid evidence that their requested treatment is necessary for their injury, as benefits will not cover treatments deemed unrelated or excessive. The section confirms that no statutory benefits are payable for the cost of treatment and care to the extent that the treatment and care concerned was not reasonable and necessary in the circumstances or did not relate to the injury resulting from the motor accident concerned.
What happened in the Review panel
A pIC Medical Assessor in the first instance ruled in favour of the claimant, finding that the requested treatments were connected to the motor vehicle accident and appropriate under the circumstances. However, the insurer sought a review, which led to the Review panel reconsidering the necessity and reasonableness of the treatments. The Review panel provided insight into what claimants need to establish when seeking benefits for medical procedures.
The Review panel determined that although the motor vehicle accident contributed to the aggravation of the claimant's pre-existing degenerative spine condition, he had not sufficiently demonstrated that the proposed surgeries and nerve blocks were reasonable or necessary.
The Review panel highlighted several important considerations, including the availability of less invasive treatments, the claimant's reluctance towards the surgery, and the lack of severe symptoms like radiculopathy or worsening neurological signs that would justify such an intervention. Furthermore, the Review panel noted that the risks of surgery appeared to outweigh the potential benefits, further undermining the case for these treatments.
What claimants should consider
This decision underlines the importance for claimants to prove three key elements when seeking statutory benefits for treatment:
- The treatment is directly related to the injuries sustained in the motor vehicle accident;
- The treatment is reasonable in the context of the injury;
- The treatment is necessary to address the condition.
If the treatment does not meet these criteria, insurers may not be liable for the costs associated with them. The Review panel's decision reinforces that the availability of non-invasive options, hesitation to undergo treatment, and the presence (or absence) of specific symptoms are all factors that could lead to a denial of payment for such treatment. Therefore, claimants need to make sure their medical evidence clearly supports the necessity and reasonableness of the treatments they seek.
Key takeaways
Claimants must take care to establish not just a connection between the motor vehicle accident and their proposed medical treatments but also demonstrate why those medical treatments are reasonable and necessary. If these elements are not convincingly demonstrated, insurers may refuse to cover the costs of proposed medical treatment under statutory benefits.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
