PIC Decision
Allianz Australia Insurance Limited v Mataraci [2025] NSWPICMP 536
Principles
✅ Treatment relates to the injuries sustained in the accident if the accident made a material contribution, at least, to the need for treatment.
✅ Relevant, but not determinative, factors relevant to whether treatment is reasonable and necessary include whether the treatment is appropriate, whether the treatment is likely to be effective, the availability of alternative treatment, the cost-effectiveness of the treatment and whether the treatment is supported by medical experts.
Sixty-Second-Or-Less Summary
An injured Claimant says she requires a posterior L5/S1 decompression and fusion surgery as a consequence of a motor accident.
What factors does the Review Panel take into account when considering whether the proposed surgery is reasonable and necessary and related to the injuries sustained in the accident?
In Allianz v Mataraci, the Review Panel reviewed the evidence and concluded that the motor accident made a material contribution to the need for surgery in the sense that, on the balance of probabilities, the surgery would not have been required but for the accident. The Review Panel, also, found that the surgery was a reasonable response to the Claimant’s lumbar spine condition given that conservative measures had failed to resolve the Claimant’s pain.
Facts
The Claimant was injured in a motor accident on 12 February 2022 when the Insured failed to stop at a stop sign.
The Claimant subsequently requested that the Insurer approve a posterior L5/S1 decompression and fusion surgery. A Medical Assessor determined that the surgery was related to the motor accident and was reasonable and necessary.
The Insurer successfully obtained a review of the original Medical Assessor’s decision.
The Review Panel’s Decision
The Review Panel determined that the proposed surgery was related to the injuries sustained in the motor accident for the following reasons:
🟪 The accident did not need to be the sole cause of the need for the Claimant’s surgery. To establish causation, the Review Panel need only be satisfied that the accident made a material contribution to the need for the proposed surgery: AAI Limited t/as AAMI v Phillips [2018] NSWSC 1710.
🟪 After reviewing all the medical evidence, the Review Panel accepted that the motor accident made a material contribution, at least, to the need for surgery.
🟪 The Claimant’s independent condition of multiple sclerosis would not have led to the need for surgery.
🟪 But for the motor accident, and on the balance of probabilities, the surgery would not have been required.
The Review Panel also agreed that the proposed surgery was reasonable and necessary. for the following reasons: The Panel noted that the test under s 3.24(2) of the Motor Accident Injuries Act 2017, that the treatment be “reasonable and necessary“, is stricter than the “reasonably necessary” test used in the workers compensation arena, because the word “necessary” is not qualified. Treatment is either necessary or it is not.
Factors relevant to – but not determinative of – whether treatment is reasonable and necessary include:
🟪 Whether the treatment is appropriate.
🟪 Whether alternative treatment is available.
🟪 Whether the treatment is cost-effective.
🟪 Whether the treatment is actually, or potentially, effective.
🟪 Whether medical experts support the proposed treatment.
In this case the proposed surgery was reasonable and necessary because:
🟪 The surgery was clinically indicated in circumstances where non-operative treatment had not resulted in ongoing resolution of the Claimant’s lower back pain, right buttock pain and L5 radiculopathy.
🟪 Decompressing a symptomatic lumbar nerve root is appropriate given that the Claimant had already tried alternative treatment to decompress the nerve via peri-neural steroid injections and chiropractic treatment.
🟪 The likely cost of the surgery was unlikely to exceed the cost of extensive conservative care.
🟪 The decompressive surgery was likely to be effective.
Pete’s Perspective
The Review Panel’s decision in Mataraci provides a useful example of a decision maker working through the factors relevant to whether proposed treatment is reasonable and necessary and related to the injuries sustained in the accident.
PJH