Tag: Reasonable and Necessary

Ongoing Physiotherapy Not Reasonable and Necessary

Decision

Ren v QBE Insurance (Australia) Ltd [2026] NSWPICMP 684

Sixty-Second-Or-Less Summary

A Claimant has over one hundred sessions of physiotherapy, with no sustained benefit, before requesting approval for a further eight sessions.

Are the additional eight sessions of physiotherapy reasonable and necessary?

In Ren v QBE, the Medical Review Panel concluded that the further eight sessions were not reasonable and necessary because – short-term relief notwithstanding – the continuation of passive treatment discouraged the Claimant from self-managing her symptoms and encouraged her to remain inactive.

Principles

✅ The onus is on the Claimant to demonstrate that disputed treatment is reasonable and necessary, in the circumstances.

✅ Passive forms of treatment may not be reasonable and necessary if they do not encourage self-management or an increase in function, even if they provide short-term symptom relief.

Facts

The Claimant was injured in a rear-end collision on 4 July 2024.

After receiving over 100 sessions of physiotherapy, the Claimant sought approval for a further eight sessions. The Insurer declined the request on the grounds that ongoing physiotherapy, some two years post-accident, was no longer reasonable and necessary. That decision was affirmed both on Internal Review and by the primary Medical Assessor.

The Claimant successfully sought a referral to the Medical Review Panel.

The Review Panel’s Decision

The Review Panel found that the disputed physiotherapy was not reasonable and necessary for the following reasons:

🟪 The Claimant was required to demonstrate that the disputed physiotherapy treatment was both “reasonable” and “necessary”.

🟪 Factors relevant to whether treatment is “reasonable” include the appropriateness of the treatment, the availability of alternative treatment, the cost of the treatment, the actual or potential effectiveness of the treatment and the acceptance of medical experts that the treatment is appropriate or likely to be effective.

🟪 The words “in the circumstances” directs attention to the relationship between the proposed treatment and the claimant’s injuries, rather than the motor accident.

🟪 The Claimant had already received more than 100 sessions of physiotherapy without sustained benefit.

🟪 The disputed physiotherapy was not reasonable and necessary because – short term relief notwithstanding – its continuation did not encourage self-management and encouraged the Claimant to remain inactive.

My Perspective

The decision in Ren illustrates that treatment which may have been reasonable and necessary during the acute recovery phase, post-accident, may no longer be reasonable and necessary, several years post-MVA, in the absence of sustained benefit.

The Review Panel’s full reasoning on this point is worthy of being set out in full:

[117] Whilst passive therapy in the early aftermath of an injury can be used to assist the injured person become more physically active, such interventions are no longer indicated several years after the motor accident. [The Claimant] obtains only very short-term relief from the massage and passive physiotherapy interventions. There has been no overall enduring benefit from lengthy treatment. The present passive treatments do not encourage self-management of her chronic condition. These interventions also do not encourage her to become physically active or else more functional with daily activities. In fact, these interventions promote unhelpful beliefs regarding permanent injury and incapacity.

It follows that the Review Panel concluded that the disputed treatment was not reasonable and necessary merely because it provided short-term relief. The Review Panel looked at the bigger picture and determined that the disputed physiotherapy was not reasonable and necessary because its continuation was to the Claimant’s overall detriment.

PJH

The purpose of this case note is educational and should not be relied upon as legal or financial advice. My commentary is only current as at the time of publication. Readers affected by the issues raised in this case note should seek bespoke legal advice, noting that I act for CTP Insurers and I do not accept direct instructions from those injured in motor accidents.

Pointless Physiotherapy Found Not Reasonable and Necessary

Decision

AAI Limited t/as AAMI v Zawit [2026] NSWPICMP 186

Sixty-Second-or-Less Read

A Claimant sustains a back injury in a motor accident. His treating doctor immediately refers him for physiotherapy. After two years, the Claimant’s treating physio discharges him from their care and recommends a pain program, which the Insurer approves.

Is a request for further physiotherapy reasonable and necessary?

In AAMI v Zawit, the Medical Review Panel concluded further physio was not reasonable and necessary given that the prior physio had not resulted in any sustained benefit to the Claimant and further physio was unlikely to assist in their recovery.

Principles

✅ Pursuant to section 3.24(2) of the Motor Accident Injuries Act 2017, a Claimant is not entitled to statutory benefits for treatment and care where the treatment and care is not reasonable and necessary and/or not related to the injuries sustained in the motor accident.

✅ Treatment, such as physiotherapy, may not be reasonable and necessary where prior treatment of the same kind has not resulted in any sustained benefit to the Claimant.

✅ Treatment is not reasonable and necessary where it does not help in the Claimant’s recovery.

Facts

The Claimant was injured in a motor accident on 14 February 2022. He sustained injuries to his left shoulder, back and neck.

On 18 July 2024, the Claimant’s treating physiotherapist sought approval for physiotherapy treatment. On 30 July 2024, the Insurer declined the request for further physiotherapy on the grounds that the treatment was not reasonable and necessary. That determination was confirmed on Internal Review. The primary Medical Assessor, however, endorsed the request for further physio. The Insurer successfully sought referral to the Review Panel.

The Review Panel’s Decision

The Review Panel accepted that any need for physiotherapy was related to the accident because the Claimant made an early report of lumbar symptoms to his treating doctor, in February 2022, and was referred for physiotherapy at that time.

The Review Panel, however, determined that the Claimant’s physiotherapy was not reasonable and necessary for the following reasons:

🟪 The Claimant received regular physiotherapy in 2022 and 2023.

🟪 In November 2023, the Claimant’s treating physiotherapist reported that any further physiotherapy was unlikely to improve the Claimant’s chronic back pain.

🟪 In January 2024, the Claimant’s treating physiotherapist discharged the Claimant from his care and recommended full transition to exercise physiology.

🟪 In July 2024, the Insurer indicated that it was willing to approve an alternative pain program.

🟪 The claim for further physiotherapy was not reasonable and necessary in circumstances where previous physiotherapy had not resulted in any sustained improvement in the Claimant’s lumbar spine symptoms and further physiotherapy would not improve the Claimant’s recovery.

My Perspective

The decision in Zawit provides a useful illustration of how a Medical Review Panel assesses whether ongoing passive treatment measures, like physiotherapy, constitute reasonable and necessary treatment years after the accident.

Each claim, of course, turns on its own facts.

The Review Panel concluded, in this dispute, however, that further physiotherapy was not reasonable and necessary given that previous physiotherapy had not helped the Claimant. Doubtless, the Review Panel also gave weight to the fact that the Insurer had moved on from physiotherapy and approved an exercise physiologist in the context of a pain program.

PJH

The purpose of this case note is educational and should not be relied upon as legal or financial advice. My commentary is only current as at the time of publication. Readers affected by the issues raised in this case note should seek bespoke legal advice, noting that I act for CTP Insurers and I do not accept direct instructions from those injured in motor accidents.