In Brief
- When assessing causation, a Medical Assessor need only consider whether the motor accident made a material contribution to the need for treatment.
- A Medical Assessor must refer to the particular circumstances of the Claimant when determining whether the treatment is "reasonable and necessary".
Facts
The Personal Injury Commission (PIC) published its decision in Petrie v QBE Insurance (Australia) Limited [2025] NSWPICMP 188 on 4 April 2025.
The Claimant was involved in a motor accident on 18 August 2022.
The Claimant had undergone surgery at L5/S1 twice before the motor accident.
The Claimant requested approval from the Insurer for an L5/S1 fusion.
The Insurer declined the request on the grounds that the surgery was not reasonable and necessary and not related to the accident injuries.
The original Medical Assessor determined the surgery does not relate to the injury caused by the motor accident but is reasonable but not necessary in the circumstances.
The Claimant sought a review of the medical assessment.
The Review Panel's Determination
The Panel accepted the motor accident was the cause of the Claimant's increased back pain because:
- The accident was a potentially very serious head-on crash between two utilities and all of the Claimant's airbags were activated which may have saved him from very serious injury.
- The Claimant was hospitalised for two days at John Hunter Hospital and the extensive bruising chest and abdominal bruising confirmed that considerable energy was involved in the crash. That energy was sufficient to cause a lumbar spine injury.
- A further L5/S1 disc protrusion, following the accident, was confirmed by the Claimant's history, his treating doctor's contemporaneous clinical records, his treating neurosurgeon's opinion and an early lumbar spine MRI scan.
- Whilst the Claimant underwent a discectomy at L5/S1 in 2002, an L5/S1 revision laminectomy and decompression in 2012 and last complained of lower back pain on 14December 2021 (eight months before the motor accident), the Panel accepted at the time of the accident, the Claimant was not experiencing any ongoing back pain and was able to undertake all activities of daily living without restriction.
- The Claimant also provided a history of being able to return to all his normal leisure activities including at the surf club and playing Oztag following the exacerbation in late 2021 before the accident in August 2022.
The Panel accepted the surgery was reasonable and necessary in the circumstances because:
- All conservative treatment has failed to alleviate the Claimant's back pain; and
- The Claimant's two previous surgeries at the L5/S1 vertebra usually led to discal instability at that level and therefore stabilisation of that vertebra was warranted.
The Panel revoked the original Certificate and certified that the Insurer was liable to fund payment for the proposed fusion as a statutory benefit.
Why This Case is Important
The decision in Petrie demonstrates the Medical Assessor needs to be satisfied, as a matter of medical determination and as a matter of factual non-medical determination, the motor accident is a material contributing cause of the need for the proposed treatment.
If you have a query relating to any of the information in this case note please don't hesitate to get in touch with CTP Insurance Special Counsel Helen Huang today.
Additional McCabes Resources
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.
